Pattern of perioperative gabapentinoid use and risk for postoperative naloxone administration.

BACKGROUND: Single preoperative gabapentinoid (gabapentin and pregabalin) administration has been associated with respiratory depression during Phase I anaesthesia recovery. In this study, we assess for associations between chronic (home) use and perioperative administration (preoperative and postoperative) of gabapentinoids, and risk for severe over-sedation or respiratory depression as inferred from the use of naloxone. METHODS: From 2011 to 2016, we identified patients undergoing general anaesthesia discharged to standard postoperative wards and administered naloxone within 48 h of surgery in a single centre. These patients were 2:1 matched on age, sex, and type of procedure. Patient and perioperative characteristics were abstracted and compared to assess for risk for naloxone administration. RESULTS: We identified 128 patients that received naloxone after operation [odds ratio 1.2; 95% confidence interval (CI) 1.0, 1.4 per 1000 general anaesthetics]. Patients on chronic or postoperative gabapentinoid therapy were at significantly higher risk for receiving naloxone after operation. Multivariable analysis detected significant interactions between chronic and postoperative use of gabapentinoids, where continuation of chronic gabapentinoid medications into the postoperative period was associated with an increased rate of naloxone administration (6.30, 95% CI 2.4, 16.7; P=0.001). Obstructive sleep apnoea (P=0.005) and preoperative disability (P=0.003) were also associated with an increased risk for postoperative naloxone administration. Patients who received naloxone had longer hospital stays and higher rates of postoperative delirium. CONCLUSIONS: Continuation of chronic gabapentinoid medications into the postoperative period is associated with the increased use of naloxone to reverse over-sedation or respiratory depression. Such patients requiring this therapy warrant high levels of postoperative monitoring.

Surgical Site Infections in Cancer Patients with Intrathecal Drug Delivery Devices.

Objectives: Our purpose was to determine the incidence of surgical site infection (SSI) in cancer patients receiving an intrathecal drug delivery system (IDDS) and compare that rate with the incidence of SSI in the general population receiving an IDDS or spinal cord stimulator. We attempted to describe risk factors for SSIs in cancer patients treated with IDDS in terms of exposure to cancer treatments. Design: Retrospective review. Setting: Large tertiary care center. Patients: Cancer patients receiving an IDDS in 2006-2013. Methods: The incidence of SSI was determined according to the US Centers for Disease Control and Prevention definition. Medication regimens and current cancer treatment were investigated to identify immunocompromised patients during IDDS placement. Microbacteriology, treatment, and overall outcomes were investigated. Results: Sixty-four patients had an IDDS implanted in 2006-2013. SSI developed in four patients (6.2%). All four patients had received chemotherapy or radiotherapy within three months before implantation. Three of the three were receiving dexamethasone, and three of the four required explantation of the IDDS. Conclusion: The incidence of SSI was at the upper end of the published infection rates for IDDS. The risk of SSI may be increased in this population because of factors that alter the patient's immune status, including concomitant corticosteroid use, radiotherapy near the SSI, and presence of immunomodulators. The identification and mitigation of certain risk factors for this population may prevent infection in future patients.

Effects of a brief pain and smoking cessation intervention in adults with chronic pain: A randomized controlled trial.

Tobacco cigarette smokers with comorbid chronic pain experience greater difficulty quitting smoking relative to those without chronic pain. A brief smoking cessation intervention was developed to address smoking in the context of chronic pain to increase the intention to engage in smoking cessation treatment. The primary aim of this randomized controlled trial was to investigate the effects of a brief pain and smoking (BPS) cessation intervention on the willingness to consider quitting smoking in adults with chronic pain seeking treatment in a pain specialty outpatient clinic. Subjects randomized to the BPS intervention were 7.5 times more likely to endorse willingness to consider quitting smoking. Subjects who received the BPS intervention were also greater than 2.5 times more likely to report an interest in learning about cessation programs, and nearly 5 times more likely to endorse willingness to consider participating in an intensive smoking cessation program. Moreover, subjects who received the BPS intervention evinced a trend-level reduction in perceived difficulty of quitting smoking. These results contribute to a growing multidisciplinary literature examining pain-smoking interrelations and suggest that smokers with chronic pain may become more willing to consider engaging a cessation attempt as awareness increases about how continued smoking may interfere with the clinical outcomes of pain treatment. These results are also consistent with clinical practice guidelines for promoting intention to quit among smokers currently unwilling to engage a quit attempt by incorporating strategies aimed at identifying ambivalence about the continued use of tobacco.

Inpatient treatment of severe nicotine dependence in a patient with thromboangiitis obliterans (Buerger's disease).

Thromboangiitis obliterans (TAO), or Buerger's disease, is an inflammatory, occlusive, and nonatherosclerotic vascular disease that most commonly affects small and medium-sized arteries and veins. The association between tobacco use and the development of TAO is incontestable; however, a substantial number of patients with TAO continue to use tobacco despite progression of disease and amputation. Herein we describe a patient with advanced TAO whose severe, refractory nicotine dependence was successfully treated in a specialized nicotine-dependence inpatient program. After cessation of smoking, the patient's disease stabilized. Inpatient nicotine-dependence treatment may represent an alternative for recidivist smokers with severe tobacco-related disease.

Postoperative pain management following bilateral lung volume reduction surgery for severe emphysema.

This study was conducted to audit the clinical management of a continuous local anaesthetic infusion delivered by a fluoroscopically placed thoracic epidural catheter in conjunction with supplemental intravenous opioid patient controlled analgesia for postoperative pain control following bilateral lung volume reduction surgery for severe emphysema. This retrospective case series involved a random sample of 43 patients from a possible 65 patients. The mean dose of epidural bupivacaine 0.15% was 6.7 ml/h (SD 1.5), while the mean daily dose of morphine or hydromorphone was 22.5 mg/day (SD 17.9) and 4.3 mg/day (SD 3.1), respectively. Inadequate analgesia was reported by 19 (44%) patients during the first two postoperative days, but was successfully treated by individual titration of these medications. The incidence of atrial fibrillation (n = 6), premature epidural catheter dislodgement (n=6) or respiratory failure (n=3) appeared to be greater among patients who had inadequate analgesia at some stage. One patient developed excessive sedation; otherwise, there were no major complications. The use of an epidural bupivacaine infusion in conjunction with intravenous opioid patient controlled analgesia proved to be a safe and effective pain medication regimen when accompanied by individual titration of these agents in response to acute exacerbations of postoperative pain.

Differentiating Alzheimer's disease and frontotemporal dementia: receiver operator characteristic curve analysis of four rating scales.

Alzheimer's disease and frontotemporal dementia are two of the most common types of degenerative dementia. In conjunction with a complete neuropsychiatric examination, the Executive Interview, Mini-Mental State Exam, Alzheimer's Disease Scale, Pick's Disease Scale and the Informant-Based Questionnaire have been used to distinguish between these two disorders on clinical grounds. In a review of two studies, scores from these rating scales are subjected to receiver operator characteristic curve analysis to determine the cut-off value for each scale which yields the highest sensitivity and specificity with regard to differentiating between Alzheimer's disease and frontotemporal dementia. Finally, the Informant-Based Questionnaire is discussed and compared to each rating scale to demonstrate the important features and limitations of each.

Frontotemporal dementia: a clinicopathological review of four postmortem studies.

Frontotemporal dementia is a progressive dementing illness characterized clinically by personality change, disinhibition, and apathy. Neuropathologically, neuronal cell loss, astrogliosis, and microvacuolation are present in the superficial frontotemporal cortical layers, with variable involvement of subcortical and limbic structures. The clinical picture and anatomical distribution of the degenerative changes, as well as motor neuron involvement, differentiate four neuropathological groups: 1) frontal lobe type, 2) thalamostriatal type, 3) motor neuron type, and 4) asymmetrical type. The authors review the results of four large postmortem studies with a special emphasis on cliniconeuropathological correlation.

Use of the Brief Psychiatric Rating Scale as a predictor of psychiatric admission for non-suicidal patients.

OBJECTIVE: We hypothesized that a systematic determination of symptom severity would predict psychiatric admission for non-suicidal patients referred for a psychiatric evaluation in an urban emergency department (ED) setting. METHOD: In a pilot study involving consecutive patients referred for a psychiatric evaluation in an urban ED, symptom severity was quantified using the Brief Psychiatric Rating Scale (BPRS). The BPRS scores of all non-suicidal patients were subjected to receiver operator characteristic (ROC) curve analysis to determine the sensitivity, specificity, and optimal cutoff score of the BPRS in predicting admission for non-suicidal patients. RESULTS: A BPRS cutoff score of 39 had a sensitivity of 85.71 percent and a specificity of 86.11 percent. The area under the ROC curve was .8671 (Somer's D = .7342) and the standard error of the curve was .1124. The cutoff score of 39 correctly identified six of seven non-suicidal patients who were hospitalized. CONCLUSIONS: It is anticipated that use of the BPRS in the ED will be further refined when a larger patient sample is studied. Potentially, a subset of BPRS items could be identified which would be more sensitive in predicting admission than the full BPRS and increase the overall efficiency of administering the BPRS in the ED.