Minimal differences in acute postoperative pain after anterior cruciate ligament reconstruction with quadriceps versus hamstring autograft.

Studies are lacking that evaluate early postoperative pain after all-soft-tissue quadriceps tendon anterior cruciate ligament reconstruction (ACLR), particularly in young patients. The purpose of this study was to investigate differences in early postoperative pain between adolescent patients undergoing ACLR with quadriceps tendon versus hamstring autograft. A retrospective review was performed of 60 patients (mean age, 15.6 ± 1.3 years) who underwent ACLR using either quadriceps tendon (n = 31) or hamstring (n = 29) autografts between January 2017 and February 2020. Intraoperative and postoperative milligram morphine equivalents (MMEs), postanesthesia care unit (PACU) length of stay and PACU pain scores were recorded. Pain scores and supplemental oxycodone use were recorded on postoperative days (POD) 1-3. Differences were compared between the two groups. There were no statistically significant differences in age, sex, body mass index or concomitant meniscus repairs between the two groups (P > 0.05). There were no statistically significant differences in intraoperative MMEs, PACU MMEs or PACU length of stay between groups (P > 0.05). There were no statistically significant differences in maximum PACU pain scores (3.7 ± 3.0 vs. 3.8 ± 3.2; P = 0.89). Maximum pain scores on POD 1-3 were similar between groups (P > 0.05). There were no statistically significant differences in supplemental oxycodone doses between groups on POD 1-3 (P > 0.05). Adolescent patients undergoing ACLR with quadriceps tendon and hamstring autografts have similar pain levels and opioid use in the early postoperative period.

A comparison of postpartum opioid consumption and opioid discharge prescriptions among opioid-naïve patients and those with opioid use disorder.

BACKGROUND: Management of patients with opioid use disorder during the acute postpartum period remains clinically challenging as obstetricians aim to mitigate postdelivery pain while optimizing recovery support. OBJECTIVE: This study aimed to evaluate postpartum opioid consumption and opioids prescribed at discharge among patients with opioid use disorder treated with methadone, buprenorphine, and no medication for opioid use disorder, as compared with opioid-naïve counterparts. STUDY DESIGN: We conducted a retrospective cohort study of pregnant patients who underwent delivery at >20 weeks' gestation at a tertiary academic hospital between May 2014 and April 2020. The primary outcome of this analysis was the mean daily quantity of oral opioids consumed after delivery while inpatient, in milligrams of morphine equivalents. Secondary outcomes included the following: (1) quantity of oral opioids prescribed at discharge, and (2) prescription for oral opioids in the 6 weeks after hospital discharge. Multiple linear regression was used to compare differences in the primary outcome. RESULTS: A total of 16,140 pregnancies were included. Patients with opioid use disorder (n=553) consumed 14 milligrams of morphine equivalents per day greater quantities of opioids postpartum than opioid-naïve women (n=15,587), (95% confidence interval, 11-17). Patients with opioid use disorder undergoing cesarean delivery consumed 30 milligrams of morphine equivalents per day greater quantities of opioids than opioid-naïve counterparts (95% confidence interval, 26-35). Among patients who underwent vaginal delivery, there was no difference in opioid consumption among patients with and without opioid use disorder. Compared with patients prescribed methadone, patients prescribed buprenorphine, and those prescribed no medication for opioid use disorder consumed similar opioid quantities postpartum following both vaginal and cesarean delivery. Among patients undergoing cesarean delivery, opioid-naïve patients were more likely to receive a discharge prescription for opioids than patients with opioid use disorder (77% vs 68%; P=.002), despite lower pain scores and less inhospital opioid consumption. CONCLUSION: Patients with opioid use disorder, regardless of treatment with methadone, buprenorphine, or no medication for opioid use disorder consumed significantly greater quantities of opioids after cesarean delivery but received fewer opioid prescriptions at discharge.

Thoracic regional anesthesia and the impact on ventilation.

Thoracic surgical incisions can be associated with intense pain or discomfort. Postoperative thoracic pain may be multifactorial in origin. Inadequate analgesia causes respiratory dysfunction. Adequate analgesia preserves pulmonary function and may hasten recovery. Intravenous opioids are widely used but sufficient analgesia is seldom achieved in doses that permit safe spontaneous ventilation. Thoracic regional anesthesia provides profound analgesia, is opiate sparing and has minimal depressant effects on ventilation. Thoracic regional anesthesia is both an effective alternative to systemic analgesics or can be used as part of a multimodal analgesic technique.

Comparison of Continuous Adductor Canal and Femoral Nerve Blocks for Analgesia and Return of Quadriceps Function After Anterior Cruciate Ligament Reconstruction in Adolescent Patients.

PURPOSE: To compare early pain relief and late quadriceps function after anterior cruciate ligament reconstruction (ACLR) with hamstring autograft in adolescent patients treated with either a continuous femoral nerve block (cFNB) or continuous adductor canal block (cACB). METHODS: We retrospectively reviewed a consecutive series of adolescent patients who underwent ACLR and received either a cACB or cFNB for postoperative pain management. Over a 1-year period, all patients underwent ACLR with cFNBs. Over the subsequent 9 months, all patients underwent their ACLR with cACBs. Patient demographics, postoperative pain scores, opioid consumption, satisfaction and complications, and dates and results of quadriceps function derived at the Return to Sports evaluation were compared. RESULTS: Ninety-one patients (53 cFNB, 38 cACB) were reviewed. There were no differences in the demographics of the 2 groups. There were no statistically significant differences between groups in variations in postoperative pain scores (P = .21), or satisfaction with the blocks (P = .93). Patients in the cFNB group consumed a greater number of opioid doses on postoperative day 3 (2.2 ± 2.1 doses cFNB, 1.1 ± 1.6 doses cACB, P = .03) and a greater number of opioid doses overall for postoperative days 1 to 3 (mean 6.8 ± 5.3 doses cFNB, 3.8 ± 2.1 doses cACB, P = .03). There was no difference in time to return of acceptable quadriceps strength and function when comparing the 2 groups (30.9 ± 7.7 weeks cFNB, 28.9 ± 6.6 weeks cACB, P = .087). CONCLUSIONS: We found few differences in postoperative analgesic requirements when comparing patients who underwent ACLR with hamstring autograft with a cACB to those who underwent a similar procedure with a cFNB. Return of quadriceps strength and function by six months did not appear to vary with regional technique, either cACB or cFNB, employed at surgery. LEVEL OF EVIDENCE: III, Retrospective comparative study.

Hypermetabolic Syndrome and Dyskinesia After Neurologic Surgery for Labrune Syndrome: A Case Report.

A 20-year-old man with a rare neurodegenerative disease developed hypermetabolic symptoms with dyskinesia after a third ventriculostomy for hydrocephalus. The initial presentation was concerning for an acute dystonic reaction after metoclopramide was administered for nausea. He concurrently developed hypermetabolic symptoms, including hyperthermia, tachycardia, and a lactic acidosis. The diagnosis was broadened to include neuroleptic malignant syndrome, serotonin syndrome, and malignant hyperthermia. Although perhaps less intellectually satisfying but more true to clinical reality, we did not isolate a single diagnosis but treated effectively all 3 with dantrolene sodium and benzodiazepine.

The labor and birth experience of women with opioid use disorder: A qualitative study.

OBJECTIVE: This study describes the experience of pregnancy and childbirth from the perspective of women with opioid use disorder. METHODS: This qualitative study analyzed semi-structured interviews about the prenatal care and birth experience of nine women with opioid use disorder as a sub-analysis of a qualitative study of women with a history of sexual trauma. Transcripts were analyzed using inductive content analysis. RESULTS: Analysis revealed unique interactions with the healthcare system specific to pregnant women with opioid use disorder. Participants identified pregnancy as a reason to enter and maintain recovery and an increased availability of resources when pregnant. Yet during labor and birth, concerns regarding pain control, child protective services involvement and provider stigma led to negative interactions with the healthcare system. CONCLUSION: Pregnant woman with opioid use disorder face unique challenges when seeking care. The perspectives of women with a history of opioid use disorder can inform creation of a harm reduction, non-stigmatizing model of prenatal, labor and birth, and postpartum care.

Early experience with erector spinae plane blocks in children.

BACKGROUND: An erector spinae plane block is a relatively new regional anesthetic technique. Apart from case reports and small series, the literature regarding pediatric use is limited. AIM: Our objective was to determine the efficacy of the erector spinae plane block in children by measuring the heart rate response to incision. Secondary objectives included feasibility, safety, opioid consumption, and pain scores. Furthermore, we reviewed this block in children published since 2016. STUDY DESIGN: Case Series; Level of evidence, IV. METHODS: With Institutional Review Board approval, a retrospective chart review was conducted on all patients who received erector spinae plane block for surgery between October 2017 and May 2019 at a single institution. Blocks were performed under anesthesia, using ultrasound guidance prior to surgical incision. Block details and hemodynamic and analgesic data were collected. In addition, a PubMed literature review was conducted to identify all erector spinae plane block related publications in patients ≤18 years of age. RESULTS: About 164 patients, 2 days-19.4 years, weighing 2.3-94.7 kg, received erector spinae plane blocks. For more than 79% of single injection blocks, placement time was ≤10 minutes. Using a heart rate increase of <10% at skin incision as criterion, 70.1% of patients had a successful block. Only 20% required long-acting opioids intraoperatively. In a subset of infants who underwent gastrostomy surgery using a dose of 0.5 mL/kg, a local anesthetic spread of at least five dermatomes (0.1 mL/kg/dermatome) was achieved. Per the literature review, 33 publications described erector spinae plane block in 128 children. No complications were reported. CONCLUSION: Erector spinae plane blocks are relatively easy to perform in children with no complications reported to date. The efficacy of the block for a broad spectrum of surgeries, involving incisions from T1 to L4, is encouraging.

Evaluation of a Quality Improvement Intervention That Eliminated Routine Use of Opioids After Cesarean Delivery.

OBJECTIVE: To evaluate the effects of eliminating the routine use of oral opioids for postcesarean delivery analgesia on postcesarean opioid consumption. METHODS: At a tertiary care center, we implemented a quality improvement intervention among faculty practice patients undergoing cesarean delivery, which consisted of 1) eliminating routine ordering of oral opioids after cesarean delivery, 2) implementing guidelines for ordering a short course of opioids when deemed necessary, and 3) coupling opioid prescribing at discharge to patterns of opioid use in-hospital combined with shared decision-making. All patients, both before and after the intervention, were administered neuraxial opioids and scheduled acetaminophen and nonsteroidal antiinflammatory medications in the absence of contraindications. The primary outcome was the percentage of women who used any opioids postoperatively in-hospital. Secondary outcomes included the percentage of women discharged with a prescription for opioids, the quantity of opioids used in-hospital, pain scores, satisfaction, opioid-related side effects, and opioid prescriptions ordered in the 6 weeks after delivery. The effects of this intervention were assessed based on a chart review of patient data and a survey of patients in the 12 weeks before and 12 weeks after the intervention. RESULTS: We evaluated the records of 191 postcesarean delivery patients before and 181 after the intervention. Less than half of women used oral opioids in-hospital after the intervention, 82 (45%) compared with 130 (68%) before (P<.001). However, there was no change in pain scores or overall satisfaction with pain relief. Postintervention, only 40% of patients were discharged with prescriptions for opioids compared with 91% of patients before the intervention (P<.001). CONCLUSION: Eliminating routine ordering of oral opioids after cesarean delivery is associated with a significant decrease in opioid consumption while maintaining the same levels of pain control and patient satisfaction. Oral opioids are not needed by a large proportion of women after cesarean delivery.

Pregnancy and Childbirth After Sexual Trauma: Patient Perspectives and Care Preferences.

OBJECTIVE: To explore the pregnancy and childbirth experiences and preferences of women with a history of sexual trauma in order to identify trauma-informed care practices that health care providers may use to improve obstetric care. METHODS: We conducted a qualitative study consisting of semistructured interviews with women who either self-identified as having a history of sexual trauma or did not. Participants were recruited from a tertiary care ambulatory clinic and had at least one birth experience within the past 3 years. Interviews were audio-recorded and transcribed verbatim. Grounded theory was used to derive themes using the participants' own words. RESULTS: From 2015 to 2017, we interviewed 20 women with a history of sexual trauma and 10 without. Women with a history of sexual trauma desired clear communication about their history between prenatal care providers and the labor and delivery team. In the intrapartum period, they desired control over who was present in the labor room at the time of cervical examinations and for health care providers to avoid language that served as a stressing reminder of prior sexual trauma. They wanted control over the exposure of their bodies during labor and to be asked about their preference for a male health care provider. In the postpartum period, some women with a history of sexual trauma found breastfeeding healing and empowering. CONCLUSION: Women with a history of sexual trauma have clear needs, preferences, and recommendations for obstetric care providers regarding disclosure, cervical examinations, health care provider language, body exposure, and male health care providers. They offer insight into unique breastfeeding challenges and benefits.

Factors Associated With Excessive Gestational Weight Gain: Review of Current Literature.

BACKGROUND: Excessive gestational weight gain (EGWG) places women at increased risk for complications during pregnancy and also increases the likelihood that they will remain overweight after pregnancy. The Institute of Medicine (IOM) has recommended weight gain guidelines based on pre-pregnancy body mass index (BMI), but evidence-based strategies to achieve these goals are limited. OBJECTIVE: This review discusses factors associated with EGWG with the goal of identifying targets for future intervention. METHODS: A search was performed using the PubMed database to identify all English-language papers published between 1995 and 2014 related to excessive weight gain in pregnancy. Papers were grouped by theme: preconception BMI, sociodemographics, diet and exercise, psychosocial characteristics, and type of prenatal care. RESULTS: Studies found that women who were overweight or obese at the time of conception were at higher risk of EGWG and that increased physical activity protected against EGWG. Studies on diet and sociodemographic characteristics were inconclusive. Psychological factors, specifically accurate perceptions of BMI, also appear to play a role in EGWG. Limited studies on methods of prenatal care delivery did not show improvement of weight parameters with group compared to one-on-one visits. CONCLUSION: Pre-pregnancy BMI is most strongly associated with EGWG, indicating that healthy weight habits throughout adult life may be especially important in periods of expected weight change, such as pregnancy. To decrease EGWG, providers should focus on improving pre-conception BMI through appropriate counseling on healthy eating and increased physical activity as well as encouraging pregnant women to continue moderate exercise during pregnancy when appropriate.

Barriers to Immediate Post-placental Intrauterine Devices among Attending Level Educators.

OBJECTIVE: To determine whether barriers to immediate post-placental intrauterine device (PPIUD) placement exist at the provider level. STUDY DESIGN: Obstetrics providers at seven academic teaching hospitals in Massachusetts were asked to complete an electronic survey regarding their knowledge, experience, and opinions about immediate PPIUDs. RESULTS: Eighty-two providers, including obstetricians, family medicine physicians, and midwives, completed the survey. Thirty-five (42.7%) reported experience placing an immediate PPIUD with the majority of them having placed three to five PPIUDs. Of participants who had never placed a PPIUD, the reason cited most frequently was inadequate training. Fewer than one-half (43.4%) correctly identified the PPIUD expulsion rate, whereas 75.9% knew the correct expulsion rate for interval IUD placement. The majority of providers responded that PPIUDs are acceptable in certain clinical scenarios. CONCLUSIONS: Overall, knowledge and experience with PPIUD placement is relatively low. As increasing numbers of states amend Medicaid policy to include reimbursement for immediate postpartum IUDs, additional education and training opportunities are needed.

Review of the assessment and management of neonatal abstinence syndrome.

Neonatal abstinence syndrome (NAS) secondary to in-utero opioid exposure is an increasing problem. Variability in assessment and treatment of NAS has been attributed to the lack of high-quality evidence to guide management of exposed neonates. This systematic review examines available evidence for NAS assessment tools, nonpharmacologic interventions, and pharmacologic management of opioid-exposed infants. There is limited data on the inter-observer reliability of NAS assessment tools due to lack of a standardized approach. In addition, most scales were developed prior to the prevalent use of prescribed prenatal concomitant medications, which can complicate NAS assessment. Nonpharmacologic interventions, particularly breastfeeding, may decrease NAS severity. Opioid medications such as morphine or methadone are recommended as first-line therapy, with phenobarbital or clonidine as second-line adjunctive therapy. Further research is needed to determine best practices for assessment, nonpharmacologic intervention, and pharmacologic management of infants with NAS in order to improve outcomes.

Self-reported pre-pregnancy weight versus weight measured at first prenatal visit: effects on categorization of pre-pregnancy body mass index.

To compare classification of pre-pregnancy body mass index (BMI) using self-reported pre-pregnancy weight versus weight measured at the first prenatal visit. Retrospective cohort of 307 women receiving prenatal care at the faculty and resident obstetric clinics at a Massachusetts tertiary-care center. Eligible women initiated prenatal care prior to 14 weeks gestation and delivered singleton infants between April 2007 and March 2008. On average, self-reported weight was 4 pounds lighter than measured weight at the first prenatal visit (SD 7.2 pounds; range: 19 pounds lighter to 35 pounds heavier). Using self-reported pre-pregnancy weight to calculate pre-pregnancy BMI, 4.2 % of women were underweight, 48.9 % were normal weight, 25.4 % were overweight, and 21.5 % were obese. Using weight measured at first prenatal visit, these were 3.6, 45.3, 26.4, and 24.8 %, respectively. Classification of pre-pregnancy BMI was concordant for 87 % of women (weighted kappa = 0.86; 95 % CI 0.81-0.90). Women gained an average of 32.1 pounds (SD 18.0 pounds) during pregnancy. Of the 13 % of the sample with discrepant BMI classification, 74 % gained within the same adherence category when comparing weight gain to Institute of Medicine recommendations. For the vast majority of women, self-reported pre-pregnancy weight and measured weight at first prenatal visit resulted in identical classification of pre-pregnancy BMI. In absence of measured pre-pregnancy weight, we recommend that providers calculate both values and discuss discrepancies with their pregnant patients, as significant weight loss or gain during the first trimester may indicate a need for additional oversight with potential intervention.

Adolescent comprehension of emergency contraception in New York City.

OBJECTIVE: To estimate comprehension of the over-the-counter emergency contraception label among female adolescents aged 12 through 17 years, and to compare the results with a similar study that focused on adults. METHODS: Surveys were administered to female adolescents in New York City in public venues such as malls, movie theaters, and parks. Participants were asked to read the emergency contraception (levonorgestrel) label before answering survey questions. Comparisons were made in SPSS version 13.0 using chi tests of independence and Fisher exact tests for sparse data. RESULTS: One thousand eighty-five girls between the ages of 12 and 17 participated in the study. Overall, adolescents demonstrated high comprehension of the key points of emergency contraception: (1) that it is a method of preventing pregnancy 92% (confidence interval [CI] 91-94%); (2) that it has to be taken within the first 72 hours after unprotected intercourse 83% (CI 83-87%); (3) that if you are already pregnant emergency contraception will not be effective 87% (CI 85-89%); (4) that emergency contraception will not protect against human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) 95% (CI 94-96%); and (5) that emergency contraception should not be used as a method of long-term birth control 85% (CI 83-87%). CONCLUSION: After reading the emergency contraception (levonorgestrel) label, female adolescents aged 12 to 17 understood the information necessary to use emergency contraception safely and effectively as well as their adult counterparts. LEVEL OF EVIDENCE: III.

Exploring factors in the decision to choose sterilization vs alternatives in rural El Salvador.

CONTEXT: To explore the factors that influence rural Salvadoran women to undergo tubal sterilization versus opting for alternative methods of family planning. EVIDENCE ACQUISITION: A moderator fluent in English and Spanish conducted eleven 90-minute focus groups consisting of 5-10 women each. Eligible women in the municipality of San Pedro Perulapan, El Salvador, were identified and recruited by local health workers. Participant demographics and information about family planning decisions were collected through detailed notes and tape-recorded sessions. The tapes were transcribed verbatim, and all data were analyzed using grounded theory procedures to identify common themes. EVIDENCE SYNTHESIS: Eighty women aged 24-45 years who had previously been sterilized participated in the study. Three major themes influenced a woman's decision to undergo sterilization instead of opting for alternative forms of family planning: (1) availability: tubal sterilization is readily available, (2) fears about side effects of other methods: these women associated negative side effects with other forms of family planning, (3) effectiveness: the women in these focus groups thought sterilization was more effective than other forms of family planning. CONCLUSIONS: This study shows that there is a lack of information, and misinformation, about other effective methods of contraception, especially the intrauterine device and oral contraceptives. Reproductive health education projects, especially those providing services in locations similar to rural El Salvador, should focus on providing accurate information about all forms of contraception, including tubal sterilization.

Allergies: their role in cancer prevention.

The nature of the biological relationships between cancers and allergies has intrigued researchers and health care providers for five decades. Three hypotheses have been proposed: antigenic stimulation predicts positive associations between cancers and allergies (i.e., allergy sufferers are more likely to get cancer), whereas immunosurveillance and prophylaxis predict inverse associations (i.e., allergy sufferers are less likely to get cancer). Immunosurveillance predicts inverse associations for cancers of all tissues and organ systems, and prophylaxis predicts inverse associations specifically for cancers of tissues and organ systems that interface with the external environment. To comparatively evaluate these hypotheses, we comprehensively reviewed the literature on cancer and allergies. We located 148 papers published from 1955 through 2006 that reported results of 463 studies of relationships between patients' histories of 11 specific allergies and cancers of 19 tissues and organ systems, and 183 studies of patients' histories of multiple allergies in relation to various types/sites of cancers. Analyses of these studies revealed that (1) frequencies of positive, inverse, and null allergy-cancer associations differed considerably among cancers of different tissues and organ systems; (2) more than twice as many studies reported inverse allergy-cancer associations as reported positive associations; (3) inverse associations were particularly common for cancers of the mouth and throat, brain glia, colon and rectum, pancreas, skin, and cervix but (4) particularly rare for cancers of the breast, prostate, and brain meninges, and for myeloma, non-Hodgkin's lymphoma, and myelocytic leukemia; (5) lung cancer was positively associated with asthma but inversely associated with other allergies; (6) inverse associations with allergies were more than twice as common for cancers of nine tissues and organ systems that interface with the external environment compared to cancers of nine tissues and organ systems that do not interface with the external environment; and (7) eczema, hives, and allergies to animal dander and food were most frequently inversely associated with cancers of tissues that interface with the external environment. Taken together, these results are more consistent with the prophylaxis hypothesis than the two alternatives. IgE is a widespread and ancient immunoglobulin isotype in mammals, occurring among all known marsupials, monotremes, and eutherians. The IgE system and its associated allergy symptoms may serve a common protective function: the rapid expulsion of pathogens, dangerous natural toxins, and other carcinogenic antigens before they can trigger malignant neoplasia in exposed tissues.