Clinical Considerations and Outcomes of Robotic Urologic Surgery in Obese Patients.

Obesity is associated with many significant physiological changes. These considerations are important to surgery, especially in urological procedures. Obese patients often undergo surgical procedures and are at higher risk of complications. This investigation reviews physiological and anaesthesia considerations for obese and morbidly obese patients. In addition, urological surgeries and procedures should be considered for these higher risk patients. Clinical anaesthesiologists must use detailed assessment and, when appropriate, consultation in developing safe anaesthesia plans for these patients. Newer technologies have improved safety related to airway management, advanced airway devices, and regional anaesthesia with ultrasound-guided nerve blocks, which can reduce the need for opioids postoperatively. Recent developments in drug and monitoring technologies have also been developed and can be effective for obese and morbidly obese patients undergoing urological procedures and perioperative surgery, thus improving the likelihood of safety in this higher risk population.

Low-Level Laser Therapy for Acute Pain: A Comprehensive Review.

PURPOSE OF REVIEW: An analysis of data conducted in 2015 by the National Health Interview Survey (NHIS) found that an estimated 25.3 million adults (11.2%) have experienced pain every day for the preceding 3 months, and nearly 40 million adults (17.6%) have experienced a severe level of pain. RECENT FINDINGS: Multiple reviews have analyzed the current management of acute pain; however, much of the current literature only focuses on pharmacological methods of analgesia, such as opiates, ketamine, or non-steroidal anti-inflammatory drugs (NSAIDs). Publications that discuss non-pharmacological options often criticize the limitations of available research for these therapies, making further exploration of this type of treatment necessary. The present investigation aims to summarize current knowledge on the use of low-level laser therapy (LLLT), a cold laser non-pharmacological approach, in managing acute pain and to discuss important clinical findings and considerations when it comes to utilizing this treatment option in patients.

Multi-agent Systems and Cancer Pain Management.

PURPOSE: The present investigation explores multi-agent systems, their function in cancer pain management, and how they might enhance patient care. Since cancer is a complex disease, technology can help doctors and patients coordinate care and communicate effectively. Even when a patient has a dedicated team, treatment may be fragmented. Multi-agent systems (MAS) are one component of technology that is making progress for cancer patients. Wireless sensory networks (WSN) and body area sensory networks (BASN) are examples of MAS. RECENT FINDINGS: Technology is advancing the care of patients, not only in everyday clinical practice, but also in creating accessible communication between patients and provider. Many hospitals have utilized electronic medical records (EHR), but recent advancements allowed the pre-existing infrastructure to network with personal devices creating a more congruent form of communications. Better communication can better organize pain management, leading to better clinical outcomes for patients, integrating body sensors, such as smart watch, or using self-reporting apps. Certain software applications are also used to help providers in early detections of some cancers, having accurate results. The integration of technology in the field of cancer management helps create an organized structure for cancer patients trying to understand/manage their complex diagnosis. The systems for the various healthcare entities can receive and access frequently updated information that can better provide better coverage of the patient's pain and still be within the legalities as it pertains to opioid medications. The systems include the EHR communicating with the information provided by the patient's cellular devices and then communicating with the healthcare team to determine the next step in management. This all happens automatically with much physical input from the patient decreasing the amount of effort from the patient and hopefully decreasing the number of patients' loss to follow-up.

The Emerging Role of Ketamine in Acute Postoperative Pain Management.

PURPOSE OF REVIEW: Postoperative pain (POP) is among the most unpleasant experiences that patients face after surgery. Interest in and use of N-methyl-D-aspartate (NMDA) receptor antagonists for the management of POP has increased over the years with ketamine being the most popular drug of this class. RECENT FINDINGS: Several randomized controlled trials found that the use of ketamine either alone or in combination with other medications leads to decreased postoperative pain and opioid consumption. However, there are other studies that have not found these benefits. The results as of now suggest that the role of intraoperative ketamine in postoperative pain control varies among different operative procedures. While some studies have shown promise in ketamine's potential use as a postoperative analgesic, there is still a great deal of proposed research and randomized controlled trials needed to deduce the most efficacious and tolerable form and dose of ketamine.

Update on Overactive Bladder Therapeutic Options.

BACKGROUND: Millions of Americans are burdened by overactive bladder (OAB) syndrome and the psychogenic and economic hardships that accompany it. Several theories attempt to explain OAB as a neurogenic dysfunction, myogenic dysfunction, urothelial dysfunction, or decreased expression of a channel protein secondary to bladder outlet obstruction. Given that the etiology of OAB is a working theory, the management of OAB is also an evolving subject matter in medicine. There are uncertainties surrounding the pathophysiology of OAB, the strength of a clinical diagnosis, and accurate reporting because of the disease's stigma and decreased use of health care. DATA SOURCES: This is a narrative review that used PubMed, Google Scholar, Medline, and ScienceDirect to review literature on current and future OAB therapies. RESULTS: Currently, first-line treatment for OAB is behavioral therapy that uses lifestyle modifications, bladder-control techniques, and psychotherapy. Second-line therapy includes antimuscarinic agents or beta 3 adrenergic agonists, and studies have shown that combination therapy with antimuscarinics and beta 3 adrenergic agonists provides even greater efficacy than monotherapy. Third-line therapies discussed include onabotulinumtoxinA, posterior tibial nerve stimulation, and sacral neuromodulation. OnabotulinumtoxinA has been FDA-approved as a nonpharmaceutical treatment option for refractory OAB with minimal side effects restricted to the urinary tract. Posterior tibial nerve modulation and sacral neuromodulation are successful in treating refractory OAB, but the costs and complication rates make them high-risk procedures. Therefore, surgical intervention should be a last resort. Estrogen therapy is effective in alleviating urinary incontinence in postmenopausal women, consistent with the association between estrogen deficiency and genitourinary syndrome. Potassium channel activators, voltage-gated calcium channel blockers, and phosphodiesterase inhibitors look to be promising options for the future of OAB management. As new therapies are developed, individuals with OAB can better personalize their treatment to maximize their quality of life and cost-effective care.

Treatment of Acute Pain in Patients on Naltrexone: A Narrative Review.

PURPOSE OF REVIEW: The tissue damage and trauma associated with surgery almost always result in acute postoperative pain. The intensity of postoperative pain can range from mild to severe. Naltrexone is suitable for patients who do not wish to be on an agonist treatment such as methadone or buprenorphine. However, naltrexone has been shown to complicate postoperative pain management. RECENT FINDINGS: Multiple studies have found that the use of naltrexone can increase the opioid requirement for postoperative pain control. Other modalities exist that can help outside of opioids such as ketamine, lidocaine/bupivacaine, duloxetine, and non-pharmacological management can help manage pain. Multimodal pain regiments should also be employed in patients. In addition to traditional methods for postoperative pain management, other methods of acute pain control exist that can help mitigate opioid dependence and help control pain in patients who use naltrexone for their substance use disorders.

Tetracycline-, Doxycycline-, Minocycline-Induced Pseudotumor Cerebri and Esophageal Perforation.

Tetracyclines are a class of broad-spectrum bacteriostatic antibiotics used to treat many infections, including methicillin-resistant Staphylococcus aureus (MRSA), acne, pelvic inflammatory disease, chlamydial infections, and a host of zoonotic infections. These drugs work by inhibiting protein synthesis in bacterial ribosomes, specifically by disallowing aminoacyl-tRNA molecules from binding to the ribosomal acceptor sites. While rare, tetracycline antibiotics, particularly minocycline and doxycycline, are associated with an increased risk of developing esophageal perforation and pseudotumor cerebri (PTC, or idiopathic intracranial hypertension). Since tetracyclines are a commonly prescribed class of medications, especially in adolescents for acne treatment, it is important for clinicians to appreciate significant side effects that can result in morbidity and mortality. This paper aims to consolidate and to emphasize current research on the association between tetracycline antibiotics and the development of esophageal perforation, and PTC. PTC is a neurological syndrome consisting of increased intracranial pressure, headache, and vision changes without evidence of the contributing source, such as mass lesion, infection, stroke, or malignancy. Esophageal perforation, while rare, can be the result of pill esophagitis. Pill-induced injuries occur when caustic medicinal pills dissolve in the esophagus rather than in the stomach. Most patients experience only self-limited pain (retrosternal burning discomfort, heartburn, dysphagia, or odynophagia), but hemorrhage, stricture, and perforation may occur. Tetracycline use can lead to pill esophagitis. In summary, clinicians should appreciate the potential risks of tetracycline compounds in clinical practice.

Aminoglycoside-Related Nephrotoxicity and Ototoxicity in Clinical Practice: A Review of Pathophysiological Mechanism and Treatment Options.

Aminoglycosides are a class of medications used to treat certain bacterial infections, specifically gram-negative aerobes. These drugs can be used alone as first-line treatments or in combination with other medications. There can be many different formulations of aminoglycosides including oral, inhalants, intravascular, intramuscular, or intraventricular. There are many distinctive types of aminoglycosides, and although they provide excellent coverage, they can have a wide variety of side effects. The most prevalent side effects of aminoglycosides are nephrotoxicity and ototoxicity. Aminoglycoside-induced nephrotoxicity is concerning because of the effects that abnormal creatinine levels can have on other drugs and the potential for neurotoxicity. Fortunately, changes in renal function are typically reversible. The kidney is affected by the drug's ability to enter the proximal tubule and cause a buildup of phospholipids in the lysosomes, inhibiting their function. Exposure to aminoglycosides in utero can result in permanent ototoxicity. The mechanism of ototoxicity is through the drug's ability to freely pass into hair cells and cause reactive oxygen species to damage the mitochondria, resulting in cell death. There is not a substantial amount of research regarding the prevention and treatment of adverse effects of aminoglycosides. Future research on the mediation or modulation of these pathophysiological processes would expand their usage in modern medicine.

Hereditary Angioedema: Diagnosis, Clinical Implications, and Pathophysiology.

Hereditary angioedema (HAE) is an autosomal dominant disorder caused by a mutation in the C1 esterase inhibitor gene. HAE affects 1/50,000 people worldwide. Three main types of HAE exist: type I, type II, and type III. Type I is characterized by a deficiency in C1-INH. C1-INH is important in the coagulation complement, contact systems, and fibrinolysis. Most HAE cases are type I. Type I and II HAE result from a mutation in the SERPING1 gene, which encodes C1-INH. Formally known as type III HAE is typically an estrogen-dependent or hereditary angioedema with normal C1-INH activity. Current guidelines now recommend subdividing hereditary angioedema with normal C1 esterase inhibitor gene (HAE-nl-C1-INH formerly known as HAE type III) based on underlying mutations such as in kininogen-1 (HAE-KNG1), plasminogen gene (PLG-HAE), myoferlin gene mutation (MYOF-HAE), heparan sulfate-glucosamine 3-sulfotransferase 6 (HS3ST6), mutation in Hageman factor (factor XII), and in angiopoietin-1 (HAE-ANGPT-1). The clinical presentation of HAE varies between patients, but it usually presents with nonpitting angioedema and occasionally abdominal pain. Young children are typically asymptomatic. Those affected by HAE usually present with symptoms in their early 20s. Symptoms can arise as a result of stress, infection, or trauma. Laboratory testing shows abnormal levels of C1-INH and high levels of bradykinin. C4 and D-dimer levels can also be monitored if an acute HAE attack is suspected. Acute treatment of HAE can include IV infusions of C1-INH, receptor antagonists, and kallikrein inhibitors. Short- and long-term prophylaxis can also be administered to patients with HAE. First-line therapies for long-term prophylaxis also include IV infusion of C1-INH. This review aims to thoroughly understand HAE, its clinical presentation, and how to treat it.

Safety, Efficacy, and Ease of Insertion of Gnana Laryngeal Airway (GLA-4): A Prospective Clinical Study Utilizing the Unique Laryngeal Mask Airway With a Suction Tubing.

INTRODUCTION: Utilizing laryngeal mask airways to maintain patients' airways is advantageous because it enables the anesthesiologist to keep the patient spontaneously inhaling and is less traumatic to the airway than intubation. Newer designs such as the Gnana laryngeal mask airway design permit real-time suctioning while the mask is on a patient. METHODS: This is a prospective observational study of the efficacy of Gnana laryngeal airway 4 (GLA-4) in 50 patients undergoing colonoscopy. Induction and maintenance of anesthesia were provided with propofol; GLA-4 was applied to secure the airway; and correct placement was verified. RESULTS: Fifty patients were included in the study (44% female, 56% male, mean age: 56.5 years, mean BMI: 33.3). Twelve patients were assigned American Society of Anesthesiologists (ASA) class 2, and 38 were assigned ASA class 3. The first attempt of GLA-4 insertion was successful in 47 patients, and two attempts were required for the successful placement of the GLA-4 in two patients. The successful placement was not achieved in one patient. The average time to successful insertion was 27.1 ± 3.9s. The average volume of oropharyngeal secretions suctioned through the suction catheter was 9.96 ± 2.31 mL. No intraoperative or postoperative complications occurred in the 50 patients. There were no reports of sore throat, hoarseness, dysphagia, or cough immediately postop. CONCLUSION: GLA-4 can be inserted safely with adequate periglottic occlusion. This laryngeal mask is unique and desirable due to its ability to evacuate oropharyngeal secretions while in place to prevent laryngospasm. To establish the role of GLA-4 in broader clinical situations, additional clinical trials and studies are required.

Effects of propofol and sevoflurane on T-cell immune function and Th cell differentiation in children with SMPP undergoing fibreoptic bronchoscopy.

OBJECTIVES: The potentially different effects of commonly used anaesthetic agents propofol and sevoflurane on T-cell immune function and Th cell differentiation were investigated in patients with severe mycoplasmal pneumonia (SMPP) undergoing fibreoptic bronchoscopy. METHODS: Sixty children (2-12 years of age) with SMPP were randomized into the sevoflurane group and the propofol group. Patients in the sevoflurane group were anaesthetised with inhalational sevoflurane and intravenous remifentanil. Patients in the propofol group were anaesthetised with intravenous propofol and remifentanil. Patients in both groups underwent fibreoptic bronchoscopy and lavage therapy. We compared the clinical outcomes, cellular immunity function, and Th cell differentiation into Th1 and Th2 levels in both groups. RESULTS: There was no significant difference in clinical outcomes and hospital stay between the two groups (7.94 vs 7.36, p > .05). However, the CD3+ T cells, CD4+ T cells, and CD4+/CD8+ in the propofol group were significantly higher than those in the sevoflurane group (T1 51.96 vs 48.33, T2 58.08 vs 55.31, p < .05). The ratio of Th1/Th2 in the two groups was significantly increased postoperatively in both groups (Sevoflurane 8.53 vs 7.23, Propofol 9.35 vs 7.18), and the propofol group was significantly higher than the sevoflurane group (9.35 vs 8.53, p < .05). CONCLUSIONS: Propofol might have a less inhibitory effect on T lymphocytes in children with SMPP than sevoflurane. And propofol may have less impact on the differentiation of Th cells into Th1 cells and better preserving the Th1/Th2 ratio than sevoflurane. KEY MESSAGESThe pathogenesis of SMPP is still unclear, likely through alveolar infiltration with neutrophils and lymphocytes, lymphocyte/plasma cell infiltrates in the peri-bronchovascular area, and immune dysfunction.Recent experimental and clinical studies showed that sevoflurane might have immunosuppressive effects, and multiple studies confirmed that the immune function of children with SMPP had been reduced.This study found that propofol administered in children with SMPP had a less inhibitory effect on T lymphocytes than inhalational sevoflurane, had little inhibitory effect on the differentiation of Th cells into Th1 cells, and better preserve Th1/Th2 ratio and maintain the balanced immune function.

Racial Disparities and Mental Health Effects Within Prostate Cancer.

Disparities in prostate cancer (PCa) exist at all stages: screening, diagnosis, treatment, outcomes, and mortality. Although there are a multitude of complex biological (e.g., genetics, age at diagnosis, PSA levels, Gleason score) and nonbiological (e.g., socioeconomic status, education level, health literacy) factors that contribute to PCa disparities, nonbiological factors may play a more significant role. One understudied aspect influencing PCa patients is mental health related to the quality of life. Overall, PCa patients report poorer mental health than non-PCa patients and have a higher incidence of depression and anxiety. Racial disparities in mental health, specifically in PCa patients, and how poor mental health impacts overall PCa outcomes require further study.

The Anticancer Effect of Metformin Combined with Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors in Non-small Cell Lung Cancer Patients with or Without Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis.

INTRODUCTION: Despite the growing evidence for the anticancer effect of metformin or its combination with epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs), the efficacies and side effects of such strategies in non-small cell lung cancer (NSCLC) patients with or without type 2 diabetes mellitus (T2DM) are not well understood. This meta-analysis was performed to determine the efficacy and side effects of metformin combined with EGFR-TKIs (MET-EGFR-TKIs) for the treatment of NSCLC with or without T2DM. METHODS: PubMed and Cochrane Library databases were used to retrieve relevant studies through August 2020 using the keywords "metformin", "EGFR-TKIs" ("gefitinib" or "erlotinib" or "afatinib" or "icotinib" or "dacomitinib") and "lung cancer". The patients in the experimental group received MET-EGFR-TKIs, while those in the control group received only EGFR-TKIs. The outcome analysis reported overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR). Random-effect models and fixed-effect models were used to estimate the combined hazard ratio (HR) and odds ratio (OR) depending on the data heterogeneity. Three studies (including 1996 patients) were included in the current meta-analysis. RESULTS: There were significant differences in PFS (HR 0.84; 95% confidence interval (CI) 0.75-0.95; P = 0.004) and OS (HR 0.77; 95% CI, 0.50-1.04; P < 0.001) between the MET-EGFR-TKI and EGFR-TKI groups. Although the ORR (OR 1.38; 95% CI 0.66-2.88; P = 0.105) and DCR (OR 2.61, 95% CI 0.68-9.95, P = 0.160) were improved, there was no statistical significance. OS subgroup analysis showed that the combination was more effective in NSCLC with T2DM than in NSCLC without T2DM (HR 0.84; 95% CI 0.74-0.95; P < 0.005). CONCLUSIONS: MET-EGFR-TKIs provided benefits for PFS and OS, and OS subgroup analysis showed that patients with NSCLC with T2DM received greater benefit than NSCLC patients without T2DM. However, further large-scale, well-designed randomized controlled trials (RCTs) are warranted to confirm the findings in the present investigation.

Pharmacological management of cancer pain: Novel therapeutics.

Patients diagnosed with cancer often experience pain during their treatment course, making it difficult to care for themselves and continue with their activities of daily living. When cancer is found at later stages, the pain can become severe and constant; reducing their quality of life and significantly affecting mental and physical well-being. Despite opioids being known to provide adequate analgesia for higher pain levels, they are often the reason for under-dosing because of their adverse effects and concern for addiction. There are also patients who do not respond well to opioids because of genetic anomalies or personal preference. Therefore, there is a need for novel non-opioid cancer pain treatments. There are many new cancer pain treatments that are emerging. This manuscript discusses cancer pain, risk factors, epidemiology, guidelines for the treatment of cancer pain, personalization of cancer pain therapy, breakthrough pain, cancer-induced peripheral neuropathy, established cancer pain treatment options, and novel emerging cancer pain treatment options.

Burst Spinal Cord Stimulation in the Management of Chronic Pain: Current Perspectives.

Over the last several decades, opioid diversion, misuse, and over-prescription have run rampant in the United States. Spinal cord stimulation (SCS) has been FDA approved for treatment for a primary indication of neuropathic limb pain that is resistant to more conservative medical therapy. The disorders qualified for treatment include neuropathic, post-surgical, post-amputation, osteodegenerative, and pain related to vascular disease. Some of the most frequently cited conditions for treatment of SCS include failed back surgery syndrome, complex regional pain syndrome (CRPS) Type I and Type II, and post-herpetic neuralgias. Developments in SCS systems have led to the differentiation between the delivered electromechanical waveform patterns, including tonic, burst, and high-frequency. Burst SCS mitigates traditional paresthesia due to expedited action potential and offers improved pain relief. Burst SCS has been shown in available studies to be non-inferior to the traditional SCS, which can cause pain paresthesia in patients who already have chronic pain. Burst SCS does not seem to cause or need the paresthesia seen in traditional SCS, making SCS not tolerable to patients. Moreover, some studies suggest that burst SCS may decrease opioid consumption in patients with chronic pain. This can make burst SCS an extremely useful tool in the battle against chronic pain and the raging opioid epidemic. As of now, more research needs to be performed to further delineate the effectiveness and long-term safety of this device.

Platelet-Rich Plasma Injections: Pharmacological and Clinical Considerations in Pain Management.

PURPOSE OF REVIEW: Regenerative medicine through interventional pain procedures is evolving with data demonstrating efficacy for a number of pain states in recent years. Platelet-rich plasma (PRP), defined as a sample of plasma with a platelet concentration 3 to 5 times greater than the physiologic platelet concentration found in healthy whole blood, releases bioactive proteins which can restore anatomical function in degenerative states. PRP is dense in growth factors, such as platelet-derived growth factor, transforming growth factor-beta1, basic fibroblastic growth factor, vascular endothelial growth factor, and epidermal growth factors. RECENT FINDINGS: To date, well-designed case-control or cohort studies for the use of PRP have demonstrated efficacy in lumbar facet joint, lumbar epidural, and sacroiliac joint injections. At present, there is only level IV evidence indicating the need for larger and more carefully controlled prospective studies. PRP is utilized autogenously in order to facilitate healing and injection and has been studied in the long-term management of discogenic low back pain. In this regard, numerous studies have evaluated PRP to steroid injections in chronic pain states with favorable results. PRP represents an opportunity for a new strategy in the therapeutic treatment of degenerative states of spines, joints, and other locations throughout the body with evolving data demonstrating both safety and long-term efficacy.

Physiologic and pharmacologic considerations in morbid obesity and bariatric anesthesia.

Obesity is a growing worldwide health hazard that is characterized by excess malnutrition. Excess food intake leads to dysregulated energy homeostasis and increased adiposity, activating pro-inflammatory physiologic pathways that can contribute to the chronic inflammatory state associated with many chronic illnesses. Obesity is a preventable illness, but its multifaceted etiology, including genetic, behavioral, and environmental variables, is critical to understanding its epidemiology and pathophysiology. Obesity is a critical predisposing factor for illnesses including type II diabetes, cardiovascular disease, and cancer, with higher morbidity and death. Obesity rates are rising, and so will the need for perioperative anesthesia for subjects with obesity. Obesity epidemiology, biochemistry, and pathophysiology are significant concepts in perioperative anesthesia management for subjects with obesity. To provide optimal intraoperative care for subjects with obesity, preoperative cardiovascular assessment for coronary artery disease and drug monitoring is required. Individuals suffering from obesity have significantly higher oxygen consumption rates and a higher risk of desaturation and surgical complications. Individuals suffering from obesity require specialized perioperative treatment related to higher prevalence of perioperative complications.

Superior Block Length and Reduced Opioid Use with Dexmedetomidine and Dexamethasone regional block versus plain Ropivacaine: a retrospective trial.

Purpose: The purpose of this study is to determine if using a combination of dexamethasone and dexmedetomidine (Dex-Dex) in a single-shot perineural local anesthestic provides an increased duration of pain relief and reduced consumption of opioids for patients undergoing shoulder surgery. Patients and methods: This is a retrospective trial of adult patients without major comorbidities undergoing elective, upper arm orthopedic procedures with regional nerve block for post-operative analgesia. Patients underwent nerve block with either 0.5% ropivacaine or 0.2% ropivacaine with 5mg dexamethasone and 25mg dexmedetomidine ("dex-dex"). Patients were assessed in 1-week intervals for two weeks for duration of block analgesia, pain scores, and opioid use. Results: 31 patients were included, 12 controls and 19 in the dex-dex group. These patients underwent one of arthroscopic rotator cuff repair, reverse total shoulder repair or repair of humerus fractures. Dex-dex blocks provided significantly longer analgesia (median block time 3.5 versus 1.5 days, p<0.0001), significantly better analgesia (mean NRS 2.32 versus 8.58 on post-operative day 1, p<0.0001), and significantly reduced opioid requirements (108.16mg vs 275.63mg in MME, p<0.0001). One patient experienced transient hypotension and prolonged paresthesia in the dex-dex group. Conclusion: Preoperative single-shot interscalene nerve blocks with preservative-free dexamethasone and dexmedetomidine added as adjuvants to ropivicaine provide approximately two additional days of benefit versus ropivicaine alone. Additionally, postoperative opioid consumption is reduced.

The Impact of a Prenatal Education Program for Opioid-Dependent Mothers on Breastfeeding Rates of Infants at Risk for Neonatal Abstinence Syndrome.

INTRODUCTION: This study aimed to determine the effect of a prenatal education program for opioid-dependent women on breastfeeding frequency, newborn hospital length of stay, and cost of care for neonates at risk of developing neonatal abstinence syndrome. METHODS: From January 1, 2015 to January 1, 2020, opioid-dependent obstetric patients were educated on non-pharmacological preventative measures for neonatal abstinence syndrome (NAS), with focused counseling on breastfeeding. Data were collected and compared to a control group of opioid-dependent pregnant women who received standard care before initiation of the education program. RESULTS: Sample size calculation revealed that to detect doubling of the breastfeeding rate from 25% to 50% with 80% power and α error of 0.05, 66 participants were required in each group. CONCLUSION: There were 75 women with opioid use disorder who had prenatal NAS education (study group) and 108 women with opioid use disorder who underwent standard care before NAS education (control group). Prenatal NAS education participants significantly increased breastfeeding initiation rates compared to the control group. Newborn length of stay significantly decreased after initiation of prenatal NAS education compared to the 36 months before NAS education program.

The Influence of Analgesic Modalities on Postoperative Cancer Recurrence.

The potential for cancer cells to grow and to metastasize depends on complex interactions between inflammatory signals and pathways, immune cells, and elements of the stromal tissue in which they invade. Related to the nature of many cancers, the probability of recurrence can potentially be quite high for some patients. Immunology, lifestyle modifications, timing of disease, genetics, age, gender, and race are only a handful of ways the likelihood of cancer recurrence can be influenced. The quantity, or density, of certain immunological cells or factors, plays a role in the propagation of cancer cells. Opioids are often used in cancer patients for acute postoperative and chronic pain management. While they can produce significant pain relief, the type of analgesic utilized is important, as it may influence cancer propagation. In this regard, certain opioids have been found to increase T regulatory cells while suppressing NK cell function. Morphine may promote tumor neovascularization and expansion. Fentanyl administration significantly diminishes NK-cells and CD8+ cytotoxic T-cells. In a recent meta-analysis, propofol-based anesthesia improved both cancer-free survival and overall survival. COX inhibitors have also shown promise in persevering cancer immune function, as in literature involving ketorolac and celecoxib. In summary, inhaled anesthesia and opioids may contribute to a pro-tumor metastasis environment also known as cancer propagation; whereas propofol and COX inhibitors may provide a better alternative to reduce cancer recurrence and propagation.