Tapentadol Versus Oxycodone for Opioid-Related Adverse Drug Events and Clinical Outcomes After Inpatient Surgery.

Oxycodone is a commonly prescribed opioid for postoperative pain. However, there has been a marked increase in the use of tapentadol over the previous decade due to a perceived superior safety profile of tapentadol compared to oxycodone. There is limited real-world evidence on the safety of tapentadol compared to oxycodone after surgery. The primary objective was to examine the impact of tapentadol compared to oxycodone use on the incidence of opioid-related adverse drug events after surgery. Data for adult surgical patients receiving tapentadol or oxycodone during hospitalization between January 1, 2018, and December 31, 2021, were collected from electronic medical records of 3 tertiary metropolitan hospitals in Australia. The primary outcome was the incidence of opioid-related adverse events. Patients receiving tapentadol or oxycodone were matched using nearest-neighbour propensity score matching. In the matched cohorts (n = 1,530 vs n = 2,775; mean [standard deviation] age 62.3 [17.0] years vs 61.9 [standard deviation 17.9] years; 43% vs 45% male for the tapentadol vs oxycodone groups, respectively), patients given tapentadol experienced a similar incidence of adverse events overall (14.4%, 220/1,530 vs 12.6%, 349/2,775; P = .100; 95% CI -.35% to 3.95%). Secondary outcomes included an increased risk of delirium (2.7%, 41/1,530 vs 1.3%, 37/2,775), arrhythmias (3.4%, 52/1,530 vs 2.2%, 62/2,775), and length of hospital stay (5 [range 1-201] vs 4 [range 1-226] days) compared with oxycodone use. Further real-world studies are warranted to determine the impact of tapentadol use on a broad range of patient outcomes. PERSPECTIVE: This study provides an early signal that tapentadol use may be associated with an increased risk of some adverse events and a longer length of stay. Further research is needed to examine the impact of tapentadol use on a broad range of patient outcomes in clinical practice settings.

Prevalence and predictors of long-term opioid use following orthopaedic surgery in an Australian setting: A multicentre, prospective cohort study.

Opioid analgesics prescribed for the management of acute pain following orthopaedic surgery may lead to unintended long-term opioid use and associated patient harms. This study aimed to examine the prevalence of opioid use at 90 days after elective orthopaedic surgery across major city, regional and rural locations in New South Wales, Australia. We conducted a prospective, observational cohort study of patients undergoing elective orthopaedic surgery at five hospitals from major city, regional, rural, public and private settings between April 2017 and February 2020. Data were collected by patient questionnaire at the pre-admission clinic 2-6 weeks before surgery and by telephone call after 90 days following surgery. Of the 361 participants recruited, 54% (195/361) were women and the mean age was 67.7 years (standard deviation 10.1 years). Opioid use at 90 or more days after orthopaedic surgery was reported by 15.8% (57/361; 95% confidence interval (CI) 12.2-20%) of all participants and ranged from 3.5% (2/57) at a major city location to 37.8% (14/37) at an inner regional location. Predictors of long-term postoperative opioid use in the multivariable analysis were surgery performed at an inner regional location (adjusted odds ratio 12.26; 95% CI 2.2-68.24) and outer regional location (adjusted odds ratio 5.46; 95% CI 1.09-27.50) after adjusting for known covariates. Long-term opioid use was reported in over 15% of patients following orthopaedic surgery and appears to be more prevalent in regional locations in Australia.

Prevalence and predictors of opioid use before orthopaedic surgery in an Australian setting: A multicentre, cross-sectional, observational study.

Opioid analgesics are commonly used by patients awaiting orthopaedic surgery, and preoperative opioid use is associated with a greater burden of postoperative pain, suboptimal surgical outcomes and higher healthcare costs. This study aimed to examine the prevalence of total opioid use before elective orthopaedic surgery with a focus on regional and rural hospitals in New South Wales, Australia. This was a cross-sectional, observational study of patients undergoing orthopaedic surgery conducted between April 2017 and November 2019 across five hospitals that included a mix of metropolitan, regional, rural, private and public settings. Preoperative patient demographics, pain scores and analgesic use were collected during pre-admission clinic visits, held between two and six weeks before surgery. Of the 430 patients included, 229 (53.3%) were women and the mean age was 67.5 (standard deviation 10.1) years. The overall prevalence of total preoperative opioid use was 37.7% (162/430). Rates of preoperative opioid use ranged from 20.6% (13/63) at a metropolitan hospital to 48.8% (21/43) at an inner regional hospital. Multivariable logistic regression showed that the inner regional setting was a significant predictor of opioid use before orthopaedic surgery (adjusted odds ratio 2.6; 95% confidence interval 1.0 to 6.7) after adjusting for covariates. Opioid use prior to orthopaedic surgery is common and appears to vary by geographical location.

How to close the gaps between evidence and practice for perioperative opioids.

Excellent resources are now available that distil the best evidence around opioid prescribing in the perioperative period, including the list of recommendations provided by the international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. While some of the recommendations have been widely accepted as an essential part of postoperative practice, others have had slow and variable adoption. This article focuses on the items where theory and practice still diverge and suggests how best to close that gap. We must also remain mindful that while education is essential, it is on the lowest rung of implementation efficacy and, on its own, is a poor driver of behaviour change. Ongoing structural nudges and the use of local procedure-specific analgesic pathways will also be helpful in addressing the gap between evidence-based recommendations and practice.

Postoperative use of slow-release opioids: The impact of the Australian and New Zealand College of Anaesthetists/Faculty of Pain Medicine position statement on clinical practice.

Dose titration with immediate-release opioids is currently recommended for acute pain. The Australian and New Zealand College of Anaesthetists and the Faculty of Pain Medicine released a statement in March 2018 supporting their use in the treatment of opioid-naïve patients; however, the impact of this statement on clinical practice is currently unknown. This retrospective cohort study was conducted to compare opioid prescribing patterns before and after the release of the recommendations. Data were collected on 184 patients (2017, n = 78; 2018, n = 106) admitted to the Prince of Wales Hospital in November 2017 and 2018, which consisted of demographic data, opioid prescriptions and discharge opioid information. The main outcome is the number of prescriptions of slow-release opioids in 2017 versus 2018 after the recommendations were published. Confounding factors were accounted for using logistic and multiple regression as appropriate. There was a 29% decrease in slow-release opioid prescriptions during hospitalisation (n = 31, 40% versus n = 12, 11%; P < 0.001) and 17% decrease at discharge (n = 20, 26% versus n = 9, 9%; P = 0.02) post-publication. After adjusting for confounders, the odds of slow-release opioids being prescribed postoperatively and at discharge reduced by 86% and 88%, respectively (postoperative period: odds ratio 0.14, P < 0.05; discharge: odds ratio 0.12, P < 0.05). In addition, orthopaedic patients were more likely to receive slow-release opioids, consistent with existing literature. As the use of slow-release opioids has been associated with increased harm and protracted opioid use compared to immediate-release opioids, it is hoped that wider dissemination of these recommendations and a change in prescribing practice can be a step towards overcoming the opioid crisis.

How preparation to touch or grasp alters visual size perception.

Prior studies have suggested that visually guided actions are resistant to the effects of some pictorial size illusions, e.g., the maximum grip aperture component of a grasp for an element of the Ebbinghaus illusion display. We present evidence that when participants prepare to grasp, the reduction in illusion magnitude observed for action components is also present for conscious perceptual judgments. Our studies characterize how visual size perception changes when we choose to engage in different size-mediated behaviors. Even when the stimuli used were identical for two different tasks, we found that available information was processed differently. In the studies, participants always selected which of the two targets was larger. In some conditions, the context in which the targets were presented induced a visual illusion of size. We varied the sizes of target pairs to assess the magnitude of these visual illusions. In some tasks, participants indicated their size choice verbally. For other tasks, participants reached to grasp or touch the target that they perceived as larger. Illusion magnitudes were smaller when participants engaged in actions directed at a target or when participants imagined performing those actions. This shift in visual processing persisted for several minutes after participants switched back to a verbal, non-grasping, non-touch task. A motor interference task eliminated the reduction in illusion magnitude.

From Archive to Evidence: Historians and Natural Resource Litigation.

Within the field of natural resource law are several specific areas that are well suited for the historian's skillset and knowledge. The deployment of the historian's tool box when conducting research in the legal world, however, can result in deliverables which vary significantly from those found in the academy, as they range widely in both size and scope and do not always use the full range of a historian's skills. New technological platforms provide consulting historians with creative opportunities to disseminate valuable information and sources and enhance important scholarly debates.

Thoughts in space: the impact of environmental surround on cognitive processing.

The embodied cognition perspective has provided a formalization of the idea that the motor state is a characteristic of being that permeates all of human processing. We review this perspective and experimental evidence supporting its claim. It is further considered that the motor behaving human moves within various spaces, each affording different actions. To this end, it is proposed that the environmental surround is a critical variable in the embodied cognition perspective. Thoughts, inasmuch as they may be grounded in simulation of motor-behavioural responses, require time but also space. We suggest that these time-space considerations occur within a proposed concept of the potentiated state.

Independent evolution of visual and electrosensory specializations in different lineages of mormyrid electric fishes.

African mormyrid fishes are by far the most diverse group of osteoglossomorph (bony tongue) fishes. Mormyrids communicate using pulses of electricity, and they process electric communication signals in the midbrain exterolateral nucleus (EL). In its ancestral form, the EL is relatively small and homogenous. In two different lineages, however, the EL expanded in size and increased in cytological complexity. This evolutionary change established the perceptual ability to distinguish variation in electric pulse waveform, which plays an important role in species recognition and mate choice. However, the sensory basis of social behavior in species with a small, homogenous EL remains unknown. Using published species descriptions, we found that species in one of these lineages have relatively large eyes. Using sectioned brains, we measured the volume of a major visual region, the optic tectum (OT), and found that this same lineage also has an enlarged OT. We also found that eye size and OT size are highly correlated across species. Phylogenetic analysis suggests that a reduced visual system evolved with the origins of an active electrosense, and that this one particular lineage secondarily evolved an enlarged visual system. Behavioral tests revealed that this enlargement of the visual system established increased visual acuity. Thus, our findings demonstrate that different lineages of mormyrids have evolved visual or electrosensory specializations, but that no lineages have specialized in both. This sensory divergence likely reflects fundamentally different ecologies and suggests that vision may play an especially important role in the social behavior of mormyrids that cannot detect variation in electric signal waveform. Our findings provide an example of evolutionary change in multiple sensory systems among closely related species that lays a foundation for relating ecological adaptation to evolutionary change in multisensory perception and social behavior.

Using touch or imagined touch to compensate for loss of proprioception: a case study.

Proprioception is the sense of the position of one's own body. Here, we present a case study of an individual with proprioceptive loss in one limb consequent to stroke. The patient indicated that merely touching his impaired arm with his unimpaired arm temporarily restored his proprioception. We examined this claim and the effects of imagined touch by the unimpaired arm. Assessments were made using three-dimensional tracking of reaching trajectories towards targets in conditions of light and darkness. Both actual and imagined touching significantly reduced movement error and jerk, specifically for targets located in regions that both hands would be able to reach.

Timing of anticipatory muscle tensing control: responses before and after expected impact.

It is widely accepted that human motor control is anticipatory in nature. Previous studies have used electromyography (EMG) to examine muscle responses to falling objects and identified anticipatory muscle tensing (AMT) as a spike in activation that occurs prior to object impact. Some studies have suggested that humans use an internal model of gravity to mediate precisely timed AMT responses. The present study further examines predictive motor control through the analysis of AMT during an object catching task. For some trials, participants watched an object falling toward the hand; for other trials, their eyes were closed. For some trials, the object fell downward and impacted the hand; for other randomly selected trials, the object abruptly stopped 12 cm above the hand, enabling an assessment of the effect of impact anticipation independent of the reflexive tactile response associated with an actual impact. In Experiment 1, AMT did not shift for approximately 113 ms after the abrupt stop of the ball. In Experiment 2, we randomly varied the start height of the object and found well-timed AMT with a 129-ms lag time. A control system based on simple memory for fall time duration cannot explain these findings. We argue that an AMT control system with a lag time of approximately 121 ms could not perform with human levels of accuracy without accounting for the acceleration of downward moving objects.

Interactions between imagined movement and the initiation of voluntary movement: a TMS study.

OBJECTIVE: The purpose was to examine motor imagery-induced enhancement in corticospinal excitability during a reaction time (RT) task. METHODS: Nine young and healthy subjects performed an isometric finger flexion tasks in response to a visual imperative cue. In the pre-cue period, they were instructed to: (1) rest; (2) imagine flexing their fingers isometrically (ImFlex); or (3) imagine extending their fingers isometrically (ImExt). Surface EMGs from the finger flexors and extensors were monitored to ensure EMG silence before movement onset. Transcranial magnetic stimulation (TMS) was used to evaluate changes in motor-evoked potentials (MEP) in the finger flexor and extensor muscles during the response phase. TMS was delivered either with the imperative cue, or 120 ms before and after the imperative cue. RESULTS: RT was slower when they were imagining finger extension prior to the visual imperative cue. MEPs were significantly increased for the finger flexors during imagined finger flexion and for the finger extensors during imagined finger extension at both TMS delivery time points, reflecting movement specific enhancement in corticospinal excitability during motor imagery. When TMS was delivered 120 ms after the cue, finger flexor MEPs were further facilitated under the Rest and ImFlex conditions, but not under the ImExt condition, suggesting additive interactions between imagery-induced enhancement and early rise in corticospinal excitability during the initiation of a reaction time response. CONCLUSIONS: Our results provide neurophysiological evidence mediating dynamic interactions between imagined movement and the initiation of voluntary movement. SIGNIFICANCE: Motor imagery can be integrated into a rehabilitation protocol to facilitate motor recovery.

Planning to reach for an object changes how the reacher perceives it.

Three experiments assessed the influence of the Ebbinghaus illusion on size judgments that preceded verbal, grasp, or touch responses. Prior studies have found reduced effects of the illusion for the grip-scaling component of grasping, and these findings are commonly interpreted as evidence that different visual systems are employed for perceptual judgment and visually guided action. In the current experiments, the magnitude of the illusion was reduced by comparable amounts for grasping and for judgments that preceded grasping (Experiment 1). A similar effect was obtained prior to reaching to touch the targets (Experiment 2). The effect on verbal responses was apparent even when participants were simply instructed that a target touch task would follow the verbal task. After participants had completed a grasping task, the reduction in the magnitude of the illusion remained for a subsequent verbal-response judgment task (Experiment 3). Overall, the studies demonstrate strong connections between action planning and perception.

The movement-specific effect of motor imagery on the premotor time.

The purpose of this study was to investigate the effect of motor imagery on the premotor time (PMT). Twelve healthy adults performed reaction time movements in response to external visual signals at rest, when holding an object (muscle activation), or performing different background imagined movements (motor imagery). When compared to rest, muscle activation reduced the PMT; imagined finger extension of the right hand and imagined finger flexion of the left hand elongated the PMT; imagined finger flexion of the right hand had no effect on the PMT. This movement-specific effect is interpreted as the sum of the excitatory effect caused by enhanced corticospinal excitability specifically for the primary mover of the imagined movement and an overall inhibition associated with increased task complexity during motor imagery. Our results clearly demonstrate that motor imagery has movement-specific effects on the PMT.

Beneficial effects of postural intervention on prehensile action for an individual with ataxia resulting from brainstem stroke.

PRIMARY OBJECTIVE: This paper examined the effectiveness of postural training on upper extremity performance in an ataxic individual. The ataxia resulted from a brain stem stroke. RESEARCH DESIGN: Before-after, single-subject experimental design. EXPERIMENTAL INTERVENTION: Four-week course of postural training, comprised of three one-hour sessions/week. MAIN OUTCOMES AND RESULTS: The patient demonstrated an increase in function of the ataxic limb, as evidenced by appreciable increases in the Fugl-Meyer score and modest increases in the Postural Assessment Scale for Stroke Patients (PASS) score. CONCLUSIONS: Improvement in postural control influences upper extremity function affecting the speed and accuracy of the movement. We demonstrate the effectiveness of using postural training as an intervention towards reducing the effects of ataxia, a movement coordination impairment for which relatively few therapeutic techniques have been specifically developed or evaluated.

The effect of motor imagery on spinal segmental excitability.

The purpose of this study was to investigate the effect of motor imagery on spinal segmental excitability by recording the reflex responses to externally applied stretch of the extrinsic finger flexors and extensors during the performance of an imaginary task. Nine young healthy subjects performed a series of imagined flexion-extension movements of the fingers. Muscle stretch was imposed concurrently by applying rotations of the metacarpophalangeal joints at 100, 300, or 500 degrees /sec. Three of the nine tested subjects also generated 0.2 Newton meter voluntary flexion torque in preloading tasks before stretch. At 300 degrees /sec stretch, electromyogram (EMG) and torque reflex responses, which were observed in the finger flexors in four of nine subjects during motor imagery, were activated at a short latency (38.6 +/- 10.6 msec). This latency was similar to that recorded during a stretch of preactivated flexor muscles (34.4 +/- 3.6 msec), in which motoneurons are already suprathreshold and in which monosynaptic effects of muscle afferents are likely to be discernable. In a similar manner, for stretches imposed at 500 degrees /sec, responses to stretch of the flexors were observed in all five tested subjects in imaginary flexion tasks at very short latencies (26.4 +/- 3.7 msec), again similar to those induced by tendon taps (22.8 +/- 1.2 msec). No EMG response was observed at rest during stretches. These observations support the view that effects must have been mediated by imagery-related subthreshold activation of spinal motoneurons and/or interneurons, rather than by long-latency transcortical reflex responses. We conclude that motor imagery has a potent effect on the excitability of spinal reflex pathways.

Simulation of bilateral movement training through mirror reflection: a case report demonstrating an occupational therapy technique for hemiparesis.

In rehabilitation for hemiparesis, one of the goals of an occupational therapist is to practice upper extremity tasks with the recovering individual. The practice is intended to strengthen muscles and refine movements. It also provides examples for the recovering body and brain as they attempt to reestablish the now delicate cognitive and neural connections mediating voluntary behavior. However, the paresis significantly limits the movement sequence possibilities that may be physically practiced. We outline a method for using simulation of movement, which is intended to provide a means for experiencing a range of smooth and controlled movements completed by a paretic limb. The simulation provides a compelling perceptual experience of bilateral motion beyond the current capabilities of the affected limb. The benefits of this technique after a 3-week course of the simulation practice are exemplified by the presented case study that reveals improved function as demonstrated by increases in Fugl-Meyer scores and faster movement speeds as demonstrated by decreased movement times for the Jebsen test of hand function.

Using motor imagery in the rehabilitation of hemiparesis.

OBJECTIVE: To examine the effectiveness of using motor imagery training in the rehabilitation of hemiparesis. DESIGN: A before-after trial with clinical and behavioral analyses of single cases. SETTING: Academic-affiliated rehabilitation hospital. PARTICIPANTS: Two survivors of embolic middle cerebral artery stroke that resulted in chronic hemiparesis. INTERVENTION: A motor imagery training program consisting of imagined wrist movements (extension, pronation-supination) and mental simulations of reaching and object manipulation making use of a mirror box apparatus. Twelve 1-hour experimental sessions were delivered, 3 times a week for 4 consecutive weeks. MAIN OUTCOME MEASURES: Two clinical assessments, grip strength, 4 wrist functionality measurements, and 3 timed performance tests. All outcome measures were recorded before training began, at 3 times during the intervention month, with 2 additional long-term measurements. RESULTS: Performance of the paretic limb improved after the imagery intervention, indicated by increases in assessment scores and functionality and decreases in movement times. The improvements over baseline performance remained stable over a 3-month period. CONCLUSIONS: These results demonstrate the potential for using motor imagery as a cognitive strategy for functional recovery from hemiparesis. The intervention targets the cognitive level of action processing while its effects may be realized in overt behavioral performance.