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Background: Social and demographic factors may influence patient treatment by physicians. This study analyzes the influence of patient sociodemographics on prescription practices among hand surgeons. Methods: We performed a retrospective analysis of all hand surgeries (N = 5278) at a single academic medical center from January 2016 to September 2018. The average morphine milligram equivalent (MME) prescribed following each surgery was calculated and then classified by age, race, sex, type of insurance, and history of substance use or chronic pain. Multivariate linear regression was used to compare MME among groups. Results: Overall, patients with a history of substance abuse were prescribed 31.2 MME more than those without ( P < .0001), and patients with a history of chronic pain were prescribed 36.7 MME more than those without ( P < .0001). After adjusting for these variables and the type of procedure performed, women were prescribed 11.2 MME less than men ( P = .0048), and Hispanics were prescribed 16.6 MME more than whites ( P = .0091) overall. Both Hispanic and black patients were also prescribed more than whites following carpal tunnel release (+19.0 and + 20.0 MME, respectively; P < .001). Patients with private insurance were prescribed 24.5 MME more than those with Medicare ( P < .0001), but 25.0 MME less than those with Medicaid ( P < .0001). There were no differences across age groups. Conclusions: Numerous sociodemographic factors influenced postoperative opioid prescription among hand surgeons at our institution. These findings highlight the importance of establishing more uniform, evidence-based guidelines for postoperative pain management, which may help minimize subjectivity and prevent the overtreatment or undertreatment of pain in certain patient populations.

Background: The Rhode Island State Legislature passed the Uniform Controlled Substances Act in 2016 to limit opioid prescriptions. We aimed to objectively evaluate its effect on opioid prescribing for hand surgery patients and also identify risk factors for prolonged opioid use. Methods: A 6-month period (January-June 2016) prior to passage of the law was compared with a period following its implementation (July-December 2017). Thumb carpometacarpal arthroplasty and distal radius fracture fixation were classified as “major surgery” and carpal tunnel and trigger finger release as “minor surgery.” Prescription Drug Monitoring Database was used to review controlled substances filled during the study periods. Results: A total of 1380 patients met our inclusion criteria, with 644 prelaw and 736 postlaw patients. Patients undergoing “major surgery” saw a significant decrease in the number of pills issued in the first postoperative prescription (41.1 vs 21.0) and a corresponding decrease in morphine milligram equivalents (MMEs) (318.6 vs 159.2 MMEs) after implementation. A 30% decrease in MMEs was also seen in those undergoing “major surgery” in the first 30 days postoperatively (544.7 vs 381.7 MMEs). Risk factors for prolonged opioid use included male sex and preoperative opioid use. Conclusions: In Rhode Island, opioid-limiting legislation resulted in a significant decrease in the number of pills and MMEs of the initial prescription and a 30% decrease in total MMEs in the 30-day postoperative period after “major hand surgery.” Additional research is needed to explore the association between legislation and clinical outcomes.

Baclofen and γ-hydroxybutyrate (GHB) exert γ-aminobutyric acid (GABA)B receptor agonism and have therapeutic utility but possess different pharmacological activities. We examined whether separate groups of mice could be trained to discriminate either baclofen or GHB, and the contribution of GABAB receptors to discriminative stimulus effects. Male C57BL/6J mice were trained to discriminate either baclofen (3.2 mg/kg, intraperitoneal) or GHB (178 mg/kg, intraperitoneal) from saline under a fixed-ratio 10 schedule. The GABAB antagonist 3-aminopropyl(diethoxymethyl)phosphinic acid (CGP 35348) was used to pharmacologically assess GABAB receptor involvement. The selectivity of the resulting discriminations was assessed with the opioid agonist morphine and the benzodiazepine midazolam. In baclofen-trained mice, both baclofen and GHB were readily discriminated. Baclofen produced a maximum of 86% baclofen-appropriate responding. CGP 35348 (320 mg/kg, i.p.) produced a 4.7-fold rightward shift in the dose-effect function. GHB produced a maximum of 85.8% baclofen-appropriate responding. In GHB-trained mice, both GHB and baclofen were readily discriminated. In GHB-trained mice, GHB produced a maximum of 85.3% drug-appropriate responding; CGP 35348 (320 mg/kg, i.p.) produced a 1.8-fold rightward shift in the GHB discrimination dose-effect function. Baclofen produced up to 70.0% GHB-appropriate responding. CGP 35348 (320 mg/kg, i.p.) significantly antagonized baclofen discrimination and baclofen produced up to 37% GHB-appropriate responding up to doses that disrupted operant responding. Morphine did not produce substitution for either baclofen or GHB. Midazolam produced partial substitution for both. GHB and baclofen discrimination assays in mice provide a useful approach for examining different receptor types mediating the effects of these two drugs.

The benefits of a comprehensive enhanced recovery after surgery (ERAS) program for patients with congenital heart disease are largely unknown. This study evaluated adherence and to outcomes of a recently implemented enhanced recovery program (ERP) in congenital cardiac surgery.Patients undergoing elective procedures for simple and moderately complex congenital cardiac surgery have followed institutional ERP guidelines since October 2018. Adherence to guidelines over a 12-month period (P2) was compared with implementation data (P1, 5 months). The association of outcomes with continuous time was estimated using linear regression.Among 559 patients (representing 40% of the cardiac surgical volume) following the ERP over a period of 17 months, no differences in patient characteristics were observed between periods, except a higher incidence of previous operations in P2. Adherence to many aspects of guidelines improved from P1 to P2. The following improvements were notable: operating room extubation, 27% in P2 vs16% in P1 (P = .006); and a decrease in median ventilation time, 6.0 hours (interquartile range [IQR], 0-9.2 hours) in P2 vs 7.6 hours (IQR, 3.8-12.3 hours) in P1 (P = .002). In addition, there was a reduction in opioids, reported as oral morphine equivalents, that was most significant for intraoperative oral morphine equivalents: 5.00 mg/kg (IQR, 3.11-7.60 mg/kg) in P2 vs 6.05 mg/kg (IQR, 3.77-9.78 mg/kg) in P1 (P = .001). There was no difference in overall intensive care unit and postoperative lengths of stay, except in lower-risk surgical procedures. Surgical outcomes were similar in the 2 periods.An enhanced recovery program reduced the use of opioids, led to more extubation in the operating room, and reduced mechanical ventilation duration in patients undergoing congenital cardiac surgery.

To investigate changes in opioid use after supervised exercise therapy and patient education among knee or hip osteoarthritis patients with chronic opioid use.In this cohort study, we linked data from the Good Life with osteoArthritis in Denmark register (GLA:D®; standardised treatment program for osteoarthritis; January 2013 to November 2018) with national health registries. Among 35,549 patients, 1,262 were classified as chronic opioid users based on amount and temporal distribution of dispensed opioids the year before the intervention. We investigated changes in opioid use, measured as mg oral morphine equivalents (OMEQs), from the year before the intervention to the year after using generalized estimating equations.We found a 10% decrease in mg OMEQs from the year before to the year after the intervention (incidence rate ratio [IRR]: 0.90, 95% confidence interval [CI]: 0.86, 0.94). Additional analyses suggested this decrease to be mainly attributable to regulatory actions targeting opioid prescribing during the study period (IRR among patients participating in the intervention before: 0.98 [95% CI: 0.89, 1.07] vs after: 0.83 [0.74, 0.93] regulatory actions). In a random general population sample of matched chronic opioid users, a similar opioid use pattern was observed over time, further supporting the impact of regulatory actions on the opioid use in the study population.Among patients with knee or hip osteoarthritis and chronic opioid use, a standardised treatment program did not change opioid use when regulatory changes in opioid prescribing were taken into account.

Enhanced recovery protocols (ERPs) have the potential to streamline care and improve short-term outcomes for surgical patients. However, for patients undergoing modern iterations of complex abdominal wall reconstruction (AWR), little literature exists on the effectiveness of these protocols.In this retrospective study we reviewed our institutional experience with complex AWR throughout a 2-year period with 1 year immediately before and 1 year after implementation of our ERP. Patients undergoing primarily minimally invasive complex AWR who were compliant with 11 elements of our ERP were compared with patients who received surgery before implementation of the protocol or did not meet these criteria. Baseline patient characteristics and patient outcomes including hospital length of stay, narcotic usage, and readmission were compared across groups. Multivariable regression models were used to estimate the associations of our ERP protocol with outcomes adjusting for surgical approach.Median length of stay for the overall cohort (n = 132) was 3 days (interquartile range 1 to 4). Morbidity and mortality rates were 22.6% and 0.7%, respectively. ERP patients were less likely to have a complication (ERP compliant 8.7% [n = 46] vs non-ERP 30.2% [n = 86], plt; 0.01), had a shorter median postoperative length of stay (median 1 vs 3 days, plt; 0.01), and received fewer morphine equivalents (median 30.8 vs 45 mg, plt; 0.01). Readmission rate for ERP patients did not differ significantly vs non-ERP patients (6.5% vs 11.8%, p = 0.34).Use of ERPs in patients undergoing complex AWR may provide benefits for both patients and hospitals.

People living with chronic pain may use wearable health technology (WHT) in conjunction with an expert-directed pain management program for up to 1 year. WHT use may be associated with improvements in key patient outcomes.A 12-month study of WHT use among people with chronic pain was conducted, consisting of iPhone and Apple Watch applications to measure movement, sleep, and self-reported pain. Clinical outcomes among 105 patients enrolled in a multidisciplinary pain program that included WHT use were compared with 146 patients in the same program but without WHT, and to 161 patients receiving medical pain management without WHT.Participants used the WHT on average 143.0 (SD: 117.6) out of 365 days. Mixed-effects models revealed participants who used WHT had decreases in depression scores (-7.83, P0.01) and prescribed morphine milligram equivalents (-21.55, P =0.04) over 1 year. Control groups also showed decreases in depression scores (-5.08, P =0.01; -5.68, P0.01) and morphine milligram equivalents (-18.67, P =0.01; -10.99, ns). The estimated slope of change among the WHT was not statistically different than control groups.Patients who used WHT as part of their pain management program demonstrated a willingness to do so for extended periods of time despite living with chronic pain and other comorbidities. Data trends suggest that WHT use may positively impact depression and prescribed medication. Additional research is warranted to investigate the potential of WHT to improve the negative consequences of chronic pain.

Contains fulltext : 286719.pdf (Publisher’s version ) (Open Access) INTRODUCTION: Spinal cord stimulation (SCS) can provide long-term pain relief for various chronic pain conditions, but some patients have no relief with trial stimulation or lose efficacy over time. To "salvage" relief in patients who do not respond or have lost efficacy, alternative stimulation paradigms or anatomical targets can be considered. Dorsal root ganglion stimulation (DRG-S) has a different mechanism of action and anatomical target than SCS. OBJECTIVES: We assessed DRG-S salvage therapy outcomes in patients who did not respond to SCS or had lost SCS efficacy. MATERIALS AND METHODS: We retrospectively included consecutive patients from 2016 to 2020 who were salvaged with DRG-S after failed SCS trials (

The objective of this single-blind randomized study is to compare local infiltration of bupivacaine or liposomal bupivacaine (LipoB) in narcotic naïve patients undergoing minimally invasive lobectomy for early stage lung cancer.Adult patients without previous lung surgery undergoing minimally invasive lobectomy (robotic or thoracoscopic) for early stage lung cancer were randomly assigned to bupivacaine (with epinephrine 0.25%, 1:200 000) or LipoB 1.3%. Pain level was documented using the visual analog scale and morphine equivalents for narcotic pain medications. Inhospital treatment cost and pharmacy cost were compared.The study enrolled 50 patients (bupivacaine, 24; LipoB, 26). The mean age of patients was 66 years, 94% were non-Hispanic white, and 48% were male. There was no difference in baseline characteristics and comorbidities. Duration of surgery (105 vs 137 minutes, P = .152), chest tube duration (49 vs 55 hours, P = .126), and length of stay (2.45 vs 3.28 days, P = .326) were similar between treatments. Inhospital morphine equivalents were 42.7 mg vs 48 mg (P = .714), and the median pain score was 5.2 vs 4.75 (P = .602) for bupivacaine vs LipoB, respectively. There was no difference in narcotic use at 2 to 4 weeks (57.1% [12 of 21] vs 54.5% [12 of 22], P = 1.00), and at 6 months (5.9% [1 of 17] vs 9.5% [2 of 21], P = 1.00) after surgery. The overall cost ($20 252 vs $22 775, P = .225) was similar; however, pharmacy cost for LipoB was higher ($1052 vs $596, P = .0001).In narcotic naïve patients undergoing minimally invasive lobectomy, short-term narcotic use, postoperative pain scores, length of stay, and long-term narcotic use were similar between bupivacaine and LipoB.

Obstructive sleep-disordered breathing is commonly treated with adenotonsillectomy. Our study objective was to describe perioperative opioid dosing in children with a range of medical complexity evaluated for obstructive sleep-disordered breathing undergoing adenotonsillectomy and to investigate its association with postoperative respiratory adverse events (PRAEs).A retrospective chart review of children who underwent adenotonsillectomy and had preoperative polysomnography performed was conducted. PRAEs included requiring oxygen, jaw thrust, positive airway pressure, or mechanical ventilation. Multivariable logistic regression was performed to examine for associations between covariates and PRAEs.The cohort included 374 children with obstructive sleep-disordered breathing, median (interquartile range) age 6.1 (3.9, 9.3) years; 344 (92%) had obstructive sleep apnea (apnea-hypopnea index1 events/h) while 30 (8%) had a normal polysomnogram (apnea-hypopnea index1 events/h). The median (interquartile range) postoperative morphine-equivalent dose administered was 0.17 (0.09, 0.25) mg/kg. Sixty-six (17.6%) experienced at least 1 PRAE. Multivariable modeling identified the following predictors of PRAE: younger age at surgery (odds ratio 0.90, 95% confidence interval 0.83, 0.98), presence of cardiac comorbidity (odds ratio 2.07, 95% confidence interval 1.09, 3.89), and presence of airway anomaly (odds ratio 3.48, 95% confidence interval 1.30, 8.94). Higher total apnea-hypopnea index and morphine-equivalent dose were associated with PRAE risk, and an interaction between these variables was detected (This study identified opioid dose in morphine equivalents to be a strong predictor of PRAE. Additionally, severity of obstructive sleep apnea and postoperative morphine-equivalent dose contributed together and independently to the occurrence of PRAEs. Attention to opioid dosing, particularly among medically complex children with obstructive sleep-disordered breathing, is required to mitigate risk of PRAEs.Tsampalieros A, Murto K, Barrowman N, et al. Opioid dose and postoperative respiratory adverse events after adenotonsillectomy in medically complex children.

Postoperative pain after thoracic surgery primarily hinders patients' mobility, decreasing the quality of life. To date, various modalities have been suggested to improve postoperative pain. However, pain alleviation still remains a challenge, resulting in continued reliance on opioids. To tackle this problem, this study introduces a needle electrical twitch obtaining intramuscular stimulation (NETOIMS) as a new effective treatment modality for postoperative pain after thoracoscopic surgery.This randomized clinical trial analyzed patients receiving video-assisted thoracoscopic surgery pulmonary resection between March 2018 and June 2020 at a single institution. A total of 77 patients (NETOIMS, 36; intravenous patient-controlled analgesia, 41) were included. NETOIMS was conducted on the retracted intercostal muscle immediately following the main procedure, just before skin closure. Postoperative pain (numeric rating scale) and oral opioid morphine milligram equivalent were assessed daily until postoperative day 5.The NETOIMS group had a significantly lower numeric rating scale score on postoperative day (POD) 0 (P .01), POD2 (P .001), POD4 (P .001), and POD5 (P = .01). The predicted time to complete pain resolution was 6.15 days in the NETOIMS group and 20.7 days in the intravenous patient-controlled analgesia group. The oral opioid morphine milligram equivalent was significantly lower in the NETOIMS group on POD0 (P .001) and POD1 (P .001).NETOIMS appears to be an effective modality in alleviating postoperative pain after thoracoscopic surgery, thereby reducing the reliance on opioid use.

Opioid-based analgesia is often used in the management of postoperative pain in arthroplasty cases. This article analyses the safety of single-shot peripheral nerve block (PNB) and potential analgesic benefits in patients undergoing lower limb free flap reconstruction.A retrospective review including all patients undergoing lower limb reconstruction with free flaps between October 2017 and April 2020 was performed. Patients were divided into two groups based on PNB utilization. The use of oral opioids, post-operative pain scores, flap-related outcomes, patient morbidity, and length of hospital stay (LOS) were compared between groups.Thirty-one patients who underwent lower limb reconstruction with free flaps, were finally included in the study. Preoperative PNB was performed on 14 patients, while 17 patients received general anesthesia (GA) alone. Pain at rest, measured using the visual analog scale (VAS) score, was significantly lower (2.2 ± 1.7 vs. 4.9 ± 1.7) in the PNB group on postoperative day 1 (POD). The mean [median]±SD amounts of opioids consumed in morphine milligram equivalent (MME) were significantly lower in the PNB group on both POD1 (33.5 [22.5] ± 33.9 vs. 61.6 [48.0] ± 39.0), POD2 (29.0 [15.0] ± 29.2 vs. 58.0 [52.5] ± 37.0) and cumulatively over 7 days (164.0 [197.0] ± 132.8 vs. 315.4 [225] ± 203.2). Complication rates and LOS were not statistically different between groups, although trending toward lower take-back procedures and major complications in the PNB group.Preoperative single-shot PNB significantly reduced postoperative opioid use and patient-reported pain severity and was not associated with an increase in complication rates.

The World Health Organization Office for the Eastern Mediterranean Region (WHO/EMRO), and the recently created palliative care experts network for the Eastern Mediterranean Region (EMR), decided to develop region-specific indicators for monitoring national palliative care development in the Region.To identify relevant and feasible macro-indicators for palliative care development for the EMR.Palliative care experts from the EMR were nominated and invited to complete a 2-round Delphi study to rate macro-indicators from previous studies and propose new ones based on the EMR regional characteristics. All indicators were assessed according to regional relevance (R) and feasibility (F). A content validity index (CVI) was calculated. Indicators with CVI ≥ 0.7/1, and scoring ≥ 7/9 for the R and F averages were selected.Twelve of the 22 countries in the Region were represented in the study. In the first round, 11 indicators were selected and 13 new ones proposed. In the second round, 15 indicators matched R, F and CVI criteria. Top-scored indicators were: existence of a current national palliative care strategy (R = 8, F = 8, CVI = 1); ratio of specialized services (for adults and children) in the country per population (R = 8, F = 7, CVI = 1); allocation of funds for palliative care in the national health budget by the Ministry of Health or equivalent government agency (R = 8, F = 6, CVI = 1); education for prequalification of doctors/nurses (R = 8, F = 8, CVI = 0.9); and availability of morphine and other strong opioids (R =8, F = 8, CVI= 0.9).A baseline set of 15 region-specific indicators for measuring the development of palliative care were validated by experts in the EMR.مؤشرات كلية خاصة بإقليم شرق المتوسط لتطوير الرعاية الملطّفة في: دراسة بأسلوب دلفي.ميجيل سانشيز كارديناس، إدواردو جارالدا، داني فان ستيجن، نسيم بورغازيان، سليم سلامة، ماري شارلوت بوسو، كارلوس سينتينو وشبكة خبراء الرعاية الملطِّفة لاقليم شرق المتوسط.إن مكتب منظمة الصحة العالمية لإقليم شرق المتوسط وشبكة خبراء الرعاية الملطِّفة لإقليم شرق المتوسط، التي أُنشئت مؤخرًا، قد قررا وضع مؤشرات خاصة بالإقليم لرصد تطوير الرعاية الملطِّفة في الإقليم.هدفت هذه الدراسة الى تحديد المؤشرات الكلية المهمة والمجدية لتطوير الرعاية الملطِّفة في إقليم شرق المتوسط.جرى ترشيح خبراء في الرعاية الملطِّفة من إقليم شرق المتوسط، ودعوتهم إلى استكمال دراسة بأسلوب دلفي مكونة من جولتين، لتقييم المؤشرات الكلية من الدراسات السابقة، واقتراح مؤشرات جديدة، استنادًا إلى الخصائص الإقليمية لإقليم شرق المتوسط. وجري تقييم جميع المؤشرات حسب الأهمية الإقليمية (R) والجدوى (F). كذلك جرى حساب مؤشر صحة المحتوى (CVI). ووقع الاختيار على مؤشرات ذات صحة محتوى (CVI) تبلغ ≥ 1/0.7، وتحقق ≥ 9/7 كمتوسط على مستوى الأهمية الإقليمية (R) والجدوى (F).شارك في هذه الدراسة اثنا عشر بلدًا من بلدان الإقليم البالغ عددها 22 بلدًا. وشهدت الجولة الأولى اختيار 11 مؤشرًا واقتراح 13 مؤشرًا جديدًا. أما في الجولة الثانية، فقد جرى الوقوف على 15 مؤشرًا مطابقًا لمعايير الأهمية الإقليمية (R) والجدوى (F) وصحة المحتوى (CVI). والمؤشرات التي حصلت على أعلى الدرجات هي ما يلي: وجود استراتيجية وطنية حالية للرعاية الملطِّفة (الأهمية الإقليمية (R) = 8، الجدوى (F) = 8، صحة المحتوى (CVI) = 1)؛ ونسبة الخدمات المتخصصة (للبالغين والأطفال) في البلد لكل مجموعة سكانية (الأهمية الإقليمية (R) = 8، الجدوى (7) = 8، صحة المحتوى (CVI) = 1)؛ وتخصيص أموال للرعاية الملطِّفة في ميزانية الصحة الوطنية التي تضعها وزارة الصحة أو وكالة حكومية مكافئة (الأهمية الإقليمية (R) = 8، الجدوى (F) = 6، صحة المحتوى (CVI) = 1)؛ تثقيف الأطباء/ الممرضات بشأن الاختبار المسبق للصلاحية (الأهمية الإقليمية (R) = 8، الجدوى (F) = 8، صحة المحتوى (CVI) = 0.9)؛ وتوفر المورفين والمواد الأفيونية القوية الأخرى (الأهمية الإقليمية (R) = 8، الجدوى (F) = 8، صحة المحتوى (CVI) = 0.9).تحقق الخبراء في إقليم شرق المتوسط من مجموعة أساسية تتألف من 15 مؤشرًا خاصًّا بالإقليم لتقدير تطوير الرعاية الملطِّفة.Macro-indicateurs spécifiques à la Région pour la mise en place de soins palliatifs dans la Région de la Méditerranée orientale : étude Delphi.Le Bureau régional de l'Organisation mondiale de la Santé (OMS) pour la Méditerranée orientale et le réseau d'experts des soins palliatifs récemment créé dans la Région ont décidé de mettre au point des indicateurs spécifiques à la Région pour suivre les progrès qui y sont réalisés en matière de soins palliatifs au niveau des pays.Identifier des macro-indicateurs pertinents et réalisables pour la mise en place des soins palliatifs dans la Région de la Méditerranée orientale.Des experts en soins palliatifs de la Région de la Méditerranée orientale ont été désignés et invités à participer à une étude Delphi à deux tours pour évaluer les macro-indicateurs des études précédentes et en proposer de nouveaux en fonction des caractéristiques régionales pour la Méditerranée orientale. Tous les indicateurs ont été évalués en fonction de leur pertinence (P) et de leur faisabilité (F) au niveau régional. Un indice de validité du contenu (IVC) a été calculé. Les indicateurs ayant un indice de validité de contenu supérieur ou égal à 0,7/1, et un score supérieur ou égal à 7/9 pour les moyennes P et F ont été sélectionnés.Douze des 22 pays de la Région étaient représentés dans l'étude. Lors du premier tour, 11 indicateurs ont été sélectionnés et 13 nouveaux indicateurs ont été proposés. Lors du second tour, 15 indicateurs correspondaient aux critères P, F et IVC. Les indicateurs les mieux notés étaient les suivants : existence d'une stratégie nationale au moment de l'étude pour les soins palliatifs (P = 8, F = 8, IVC = 1) ; ratio de services spécialisés (pour adultes et enfants) dans le pays par population (P = 8, F = 7, IVC = 1) ; allocation de fonds pour les soins palliatifs dans le budget national de la santé par le ministère de la Santé ou une institution gouvernementale équivalente (P = 8, F = 6, IVC = 1) ; formation pour la préqualification des médecins/infirmiers (P = 8, F = 8, IVC = 0,9) ; et disponibilité de morphine et d'autres opioïdes puissants (P = 8, F = 8, IVC = 0,9).Un ensemble de référence de 15 indicateurs spécifiques à la Région pour mesurer la progression des soins palliatifs a été validé par des experts de la Région de la Méditerranée orientale.

Few studies have assessed interventions aimed at managing nonmedical opioid use (NMOU) behavior among patients with cancer. The authors developed the Compassionate High-Alert Team (CHAT) intervention to manage patients receiving opioids for cancer pain who demonstrate NMOU behavior. The objective of this study was to determine the change in frequency of NMOU behaviors, pain intensity, and opioid requirements among those who received the intervention.A total of 130 patients receiving opioids for cancer pain that had documented evidence of NMOU and received the CHAT intervention were reviewed. Demographic and clinical information such as NMOU behaviors, pain scores, and morphine equivalent daily dose at baseline, 3, and 6 months post-intervention was obtained.NMOU behaviors significantly decreased from a median (interquartile range) of 2 (1-3) at baseline to 0 (0-1) at both 3 and 6 months post-intervention (p .001). A total of 45 of 75 (60%) and 31 of 50 (62%) of CHAT recipients achieved complete response to the intervention at 3 and 6 months, respectively. Higher baseline number of NMOU behaviors was independently associated with patient response to the intervention (odds ratio [OR], 1.97; 95% confidence interval [CI],1.09-4.28, p = .049 at 3 months; OR, 2.5; 95% CI, 1.20-6.47, p = .03 at 6 months). The median pain score decreased from 7 at baseline to 6 at both 3 and 6 months (p = .01). Morphine equivalent daily dose did not significantly change during that same period (143 mg/day vs. 139 mg/day, p = .13).Most patients who received the CHAT intervention improved in their NMOU behaviors and pain intensity scores 3 and 6 months post-intervention. These preliminary findings support the efficacy of CHAT in managing patients receiving opioids for cancer pain who demonstrate NMOU behavior.

The United States opioid epidemic is a well-documented crisis stemming from increased prescriptions of narcotics. Online prescription drug monitoring programs (PDMPs) are a potential resource to mitigate narcotic misuse by tracking controlled substance prescriptions. Therefore, the purpose of this study was to evaluate opioid prescription trends after implementation of an online PDMP in patients who underwent single-level lumbar fusion.Patients who underwent a single-level lumbar fusion between August 27, 2017, and August 31, 2020, were identified and placed categorically into one of two cohorts: an "early adoption" cohort, September 1, 2017, to August 31, 2018, and a "late adoption" cohort, September 1, 2019, to August 31, 2020. This allowed for a 1-year washout period after Pennsylvania PDMP implementation on August 26, 2016. Opioid use data were obtained by searching for each patient in the state government's online PDMP and recording data from the year before and the year after the patient's procedure.No significant difference was observed in preoperative opioid prescriptions between the early and late adoption cohorts. The late adoption group independently predicted decreased postoperative opioid prescriptions (β, 0.78; 95% confidence interval [CI], 0.65 to 0.93; P = 0.007), opioid prescribers (β, 0.81; 95% CI, 0.72 to 0.90; P0.001), pharmacies used (β, 0.90; 95% CI, 0.83 to 0.97; P = 0.006), opioid pills (β, 0.61; 95% CI, 0.50 to 0.74; P0.001), days of opioid prescription (β, 0.57; 95% CI, 0.45 to 0.72; P0.001), and morphine milligram equivalents prescribed (β, 0.53; 95% CI, 0.43 to 0.66; P0.001).PDMP implementation was associated with decreased postoperative opioid prescription patterns but not preoperative opioid prescribing behaviors.4.

Heroin, a semisynthetic opioid drug synthesized from morphine, is the 3,6-diacetyl ester of morphine (diacetylmorphine). The post-mortem diagnosis of heroin-related death could be an issue and usually rely on a combination of investigations, including the autopsy, histological and toxicological analysis. We conducted the present study to evaluate the correlation between the heroin concentration in biological fluids (peripheral blood, bile and urine) and the post-mortem anti-6-MAM antibody expression in various tissues (brain, heart, lung, liver and kidney) using immunohistochemical staining. A quantitative analysis of the immunohistochemical reaction was carried out. 45 cases of heroin-related death investigated at the Forensic Pathology Institutes of the University of Rome, Foggia and Pisa were included. The control group was composed of 15 cases of death due to other causes, without brain lesions and negative toxicological analysis for drugs. We found a positive immunohistochemical reaction in different organs and it was related to the timing of heroin metabolization. No reaction was found in the control group. Our findings show that immunohistochemistry can be a valuable tool for the post-mortem diagnosis of acute heroin abuse. A better understanding of the timing of heroin's metabolism can be useful in the forensic field and for future therapeutic applications.

To evaluate whether enhanced recovery after surgery (ERAS) protocol implementation was associated with improved outcomes and decreased racial and ethnic outcome disparities after isolated coronary artery bypass graft (CABG) surgery.A retrospective analysis of an institutional CABG database with propensity-score matching.At a single tertiary care teaching hospital.One thousand seven hundred thirty-five patients undergoing isolated CABG: 656 patients from 2016 to 2017 (pre-ERAS) and 1,079 patients from 2018 to 2020 (post-ERAS). Each patient cohort was divided into a White subgroup and a racial and ethnic minorities (Minorities) subgroup.None MEASUREMENTS AND MAIN RESULTS: Propensity-matched post-ERAS patients (n = 584) compared to pre-ERAS patients (n = 584) demonstrated reductions in total length of stay (LOS) (median [interquartile range]): (7 [5-10] v 8 [6-11.5] days, p = .006), postoperative LOS (5 [4-7] v 5 [4-7] days, p = .001), total ventilation time (6.1 [4.8-9.5] v 6.6 [5.2-10.9] hours, p = .004), postoperative morphine milligram equivalents (mean ± standard deviation: 68.6 ± 57.5 v 100.0 ± 59.4, p.001), and increased likelihood of early extubation (48.8% v 42.3%, p = .026); the Minorities subgroup demonstrated reductions in likelihood of intensive care unit (ICU) readmission (1.3% v 8.1%, p = .012) and postoperative morphine milligram equivalents (73.6 ± 64.0 v 107.8 ± 71.9, p.001). Logistic regression models demonstrated that disparities in ICU readmission and postoperative LOS between White and Minorities patients were eliminated post-ERAS.ERAS for isolated CABG surgery was associated with reduced total and postoperative LOS, reduced total ventilation time, and increased early extubation for all patients, as well as reduced ICU readmission for the Minorities subgroup. ERAS implementation was associated with reduced disparities between White and racial and ethnic minority patients for ICU readmission and postoperative LOS.

BACKGROUND: Open-heart surgery is associated with severe postoperative pain. Adequate analgesia after open-heart surgery improves patients’ early postoperative recovery, extubation, ambulation and early discharge from hospital. Regional anaesthesia techniques are the new hope for adequate postoperative analgesia after cardiac surgery and are widely used for early pain management in the first six hours. METHODS: A total of 100 patients with the American Society of Anesthesiologists physical status classification I–III, aged 18 years and over, undergoing open-heart surgery with sternotomy for coronary artery bypass grafting or valve replacement under general anaesthesia, were included in this study. For postoperative analgesia, 50 patients with pectoral nerve (PECS II) block and 50 with parasternal (PS) block were consecutively enrolled in one of the groups at the end of the surgery and compared in terms of sedation scores, ventilation duration, pain scores at rest after extubation, block duration, total morphine consumption and complications. RESULTS: The block duration in the PS group was statistically significantly higher than in the PECS II group (p = 0.001, p < 0.05, respectively). The visual analogue scale scores at rest in the fourth and sixth hours were statistically significantly higher in the PECS II group than in the PS group (p = 0.001, p = 0.001, p < 0.01). Cumulative morphine consumption in the PECS II group was statistically significantly higher than in the PS group in the fourth, sixth, 12th and 24th hours (p = 0.001, p = 0.001, p = 0.001, p = 0.001, p = 0.001, p < 0.01, respectively). CONCLUSION: PS block provided longer block duration with lower postoperative pain and sedation scores than the PECS II block, with lower cumulative morphine consumption.

Pain management after hemorrhoidectomy continues to be challenging.The aim of this study was to evaluate the effectiveness of infiltration of bupivacaine hydrochloride and triamcinolone acetonide in surgical wounds of Milligan-Morgan hemorrhoidectomy for postoperative pain relief.A double-blind randomized controlled clinical trial was conducted between May 2015 and June 2019.This study was carried out in a secondary referral hospital center in Spain.Patients who underwent an elective Milligan-Morgan hemorrhoidectomy for grade III-IV hemorrhoids were included.Patients allocated in the intervention group received a single infiltration of bupivacaine and triamcinolone and patients allocated in the control group did not receive any intervention.The primary end point was the median of maximum pain by visual analog scale during the 48 hours of hospital stay. Secondary end points were pain at follow-up, pain during defecation, analgesic requirements, wound healing rate, and complications.A total of 128 patients were randomly assigned (64 in each group). The median of maximum pain score at 48 hours was 3 points in the intervention group and 6 points in the control group, which was significantly different ( p0.05). No differences were observed regarding pain during defecation. Morphine requirements were significant lower in the intervention group (6.3% vs 21.9% patients; p = 0.01; 5 vs 23 cumulative doses; p = 0.01). Wound healing and complication rates were similar in both groups.Use of placebo was not considered in the control group ("intervention group" vs "control group" clinical trial). Data regarding pain or other complications at 48 hours postoperatively were pooled and expressed as median of values.Infiltration of surgical wounds with bupivacaine and triamcinolone decreases postoperative pain and reduces morphine requirements in Milligan-Morgan hemorrhoidectomies. See Video Abstract at http://links.lww.com/DCR/B867 .Clinical trial registration: European Registry of Clinical Trials. EUDRACT 2014- 003043-35.ANTECEDENTES:El manejo del dolor posterior a una hemorroidectomía sigue siendo un desafío.OBJETIVO:El objetivo de este estudio fue evaluar la efectividad de la infiltración de bupivacaína y triamcinolona en heridas quirúrgicas de hemorroidectomía de Milligan-Morgan para el alivio del dolor posoperatorio.DISEÑO:Se realizó un ensayo clínico controlado, aleatorizado, doble ciego entre mayo del 2015 y junio del 2019.ENTORNO CLINICO:Este estudio se llevó a cabo en un centro hospitalario de referencia secundaria en España.PACIENTES:Se incluyeron pacientes que se sometieron a una hemorroidectomía de Milligan-Morgan electiva por hemorroides de grado III-IV.INTERVENCIONES:Los pacientes asignados al grupo de intervención recibieron una única infiltración de bupivacaína y triamcinolona y los pacientes asignados al grupo de control no recibieron ninguna intervención.PRINCIPALES RESULTADOS RESULTADOS:El factor de valoración principal fue la mediana del dolor máximo según la escala análoga visual durante las 48 horas de estancia hospitalaria. Las variables secundarias fueron dolor durante el seguimiento, dolor durante la defecación, requerimientos de analgésicos, tasa de cicatrización de heridas y complicaciones.RESULTADOS:Se asignó aleatoriamente a un total de 128 pacientes (64 en cada grupo). La mediana de puntuación máxima de dolor a las 48 horas fue de 3 puntos en el grupo de intervención y de 6 puntos en el grupo de control con diferencias significativas (p0,05). No se observaron diferencias en cuanto al dolor durante la defecación. Las necesidades de morfina fueron significativamente menores en el grupo de intervención (6,3% versus 21,9% de los pacientes; p = 0,01; 5 versus 23 dosis acumuladas; p = 0,01). Las tasas de curación de heridas y complicaciones fueron similares en ambos grupos.LIMITACIONES:No se consideró el uso de placebo en el grupo de control (ensayo clínico: "grupo de intervención" versus "grupo control"). Los datos con respecto al dolor u otras complicaciones después de 48 horas postoperatorias se agruparon y expresaron como mediana de los valores.CONCLUSIONES:La infiltración de heridas quirúrgicas con bupivacaína y triamcinolona disminuye el dolor posoperatorio y reduce los requerimientos de morfina en la hemorroidectomía de Milligan-Morgan. Consulte Video Resumen en http://links.lww.com/DCR/B867 . (Traducción- Dr. Francisco M. Abarca-Rendon).Registro de ensayos clínicos: Registro europeo de ensayos clínicos. EUDRACT 2014- 003043-35.

Single-port sleeve gastrectomy (SPSG) is increasingly performed in an ambulatory setting. Pain intensity when returning home remains a problem. The challenge is to be able to predict the evolution of postoperative pain (POP) at home by using parameters collected during the hospital stay. This study aimed to investigate whether immediate POP in the postanesthesia care unit (PACU) can predict pain intensity 24 h after surgery.Single-center retrospective study in patients with obesity who underwent ambulatory SPSG. POP and opiate requirements during PACU stay were registered. Patients were followed up at home during the first 4 postoperative days. The primary outcome was the correlation between opiate requirements in the PACU and Numerical Rating Scale (NRS) at home 24 h after surgery. Secondly, logistic regression was used to identify risk factors for moderate/intense pain 24 h after surgery.Ninety-four patients were included during the study period. Twenty-two patients had NRS 3/10 24 h after surgery. No correlation was found between the total dose of morphine in the PACU and pain intensity 24 h after surgery (rNo correlation was found between opiate requirements in the PACU and pain at home 24 h after SPSG. Based on these results, it does not seem possible to predict intense pain at home from pain profile and morphine requirement during the immediate postoperative period.

To assess pain management in patients post-sacrectomy, focusing on opioid use, and to identify the factors associated with postoperative pain.Patients who underwent resection of locally recurrent rectal cancer (LRRC) with concomitant sacrectomy at one of two hospitals between 2007 and 2020 were reviewed retrospectively. We examined the use of opioids preoperatively and postoperatively. Patients were classified into high and low sacrectomy groups based on the sacral bone resection level passing through the S3 vertebra.Sixty-four patients were enrolled. Opioid use was significantly higher in the high sacrectomy group than in the low sacrectomy group at all times assessed: on postoperative days 7, 14, 30, 90, 180, and 365. Opioid use 3 months after locally recurrent rectal cancer surgery was significantly higher in patients with local re-recurrence of the tumor than in those without re-recurrence (p 0.05), and the median morphine-equivalent opioid use 3 months postoperatively was significantly higher in the high sacrectomy group (30 vs. 0 mg/day; p 0.05).Opioid use after concomitant sacrectomy for LRRC was higher in the high sacrectomy group. Prolonged postoperative pain or increasing pain was associated with local recurrence.

Existing literature has shown the importance of palliative home care to improve quality of life among end-stage patients. However, access to palliative home care remains an issue. This study explores factors associated with successful delivery of palliative home care in palliative patients.A retrospective study was conducted among patients who were referred to the palliative care team for consultation at Lampang Hospital from April 2020 to March 2021. Data from electronic medical records, including successful delivery of palliative home care, age, gender, public health insurance, admission department, primary disease (cancer, non-cancer), presenting symptoms (pain, dyspnea), palliative performance scale score and morphine use, were retrieved. Multiple logistic regression analysis was applied to explore the association, adjusting for covariates.A total of 370 patients were identified, with 88 (23.8%) receiving palliative home care. Results showed that being female, having low palliative performance scale score, morphine use, and having Civil Servant Medical Benefit Scheme insurance are associated with a higher chance of having access to palliative home care, compared with their counterparts.Results of this study pointed out health disparities among palliative patients who required palliative home care. This information can be in part used to redesign palliative home care system with the aim of improving access to care and patients' and caregivers' quality of life as a consequence.

OBJECTIVES To determine the association of pelvic fracture displacement on lateral stress radiographs (LSR) with the hospital course of patients with minimally displaced lateral compression type 1 (LC1) pelvic injuries. DESIGN Retrospective review. SETTING Level one trauma centerPatients/Participants: 28 adult patients with minimally displaced (

A rapid, simple extraction method followed by qualitative screening using liquid chromatography–tandem mass spectrometry (LC–MS-MS) for drugs in oral fluid is presented. The decision points were selected to be at, or lower, than those recommended as Tier I compounds by the National Safety Council’s Alcohol, Drugs and Impairment Division for toxicological investigation of driving under the influence of drug (DUID) cases and were also at, or lower, than those recommended by Substance Abuse and Mental Health Service Administration and the Department of Transportation for Federal workplace drug testing programs. The method included 30 drugs: delta-9-tetrahydrocannabinol, amphetamine, methamphetamine, 3,4-methylenedioxymethamphetamine, 3,4-methylenedioxyamphetamine, cocaine, benzoylecgonine, carisoprodol, meprobamate, zolpidem, alprazolam, clonazepam, 7-aminoclonazepam, diazepam, nordiazepam, lorazepam, oxazepam, temazepam, codeine, morphine, 6-acetylmorphine, buprenorphine, fentanyl, hydrocodone, hydromorphone, oxycodone, oxymorphone, methadone, tramadol and phencyclidine. Phencyclidine was included because it is in the Federal workplace program even though it is considered a Tier II drug for DUID cases. A liquid−liquid extraction method using isopropanol, hexane and ethyl acetate to extract drugs from the oral fluid−buffer mix collected in a Quantisal™ device, followed by LC–MS-MS screening, was developed and validated according to ANSI/ASB 2019 Standard Practices for Method Validation in Forensic Toxicology. Interference studies, limit of detection, precision at the decision point, ionization suppression/enhancement and processed sample stability were determined for each drug. The method was successfully applied to proficiency specimens and routine samples received in the laboratory.

Pain control is an important topic that has not been extensively studied in patients undergoing endoscopic skull base surgery (ESBS). The purpose of this study is to identify opioid requirements after ESBS and the risk factors predictive of increased use.This study was a retrospective review of all patients undergoing ESBS at a tertiary academic skull base surgery program between July 2018 and August 2020. The primary outcome variable was total morphine equivalent dose (MED) requirements after surgery, calculated as the sum of all morphine milligram equivalents over a 24-h period, and summated across the duration of each participant's hospital course.94 patients were included in this review. Average daily MED requirements were 14.00 ± 6.79 mg. Average total MED requirements were 83.78 ± 92.99 mg during hospitalization. Average length of stay (LOS) was 5.71 ± 4.42 days, with 22 (23.4%) patients not requiring opioid use upon discharge. On multivariate analysis, female sex (β = 49.62; 95% CI [13.53, 85.71], p = 0.008), nasoseptal flap (NSF) reconstruction (β = 49.56; 95% CI [13.51, 85.61], p = 0.008) and LOS (β = 4.02; 95% CI [0.001, 8.04], p = 0.050) were independently associated with higher total MED requirements.We report average total MED requirements of 83.78 mg after ESBS, with female sex, intraoperative use of an NSF, and increased LOS as predictors of higher MED use. This data indicates a subset of patients who may benefit from more aggressive pain control strategies upfront, including consideration of non-opioid, multimodal pain regimens.3 Laryngoscope, 132:1939-1945, 2022.