Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta-analysis.

BACKGROUND: Opioids are often prescribed for acute pain to patients discharged from the emergency department (ED), but there is a paucity of data on their short-term use. The purpose of this study was to synthesize the evidence regarding the efficacy of prescribed opioids compared to nonopioid analgesics for acute pain relief in ED-discharged patients. METHODS: MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and gray literature databases were searched from inception to January 2023. Two independent reviewers selected randomized controlled trials investigating the efficacy of prescribed opioids for ED-discharged patients, extracted data, and assessed risk of bias. Authors were contacted for missing data and to identify additional studies. The primary outcome was the difference in pain intensity scores or pain relief. All meta-analyses used a random-effect model and a sensitivity analysis compared patients treated with codeine versus those treated with other opioids. RESULTS: From 5419 initially screened citations, 46 full texts were evaluated and six studies enrolling 1161 patients were included. Risk of bias was low for five studies. There was no statistically significant difference in pain intensity scores or pain relief between opioids versus nonopioid analgesics (standardized mean difference [SMD] 0.12; 95% confidence interval [CI] -0.10 to 0.34). Contrary to children, adult patients treated with opioid had better pain relief (SMD 0.28, 95% CI 0.13-0.42) compared to nonopioids. In another sensitivity analysis excluding studies using codeine, opioids were more effective than nonopioids (SMD 0.30, 95% CI 0.15-0.45). However, there were more adverse events associated with opioids (odds ratio 2.64, 95% CI 2.04-3.42). CONCLUSIONS: For ED-discharged patients with acute musculoskeletal pain, opioids do not seem to be more effective than nonopioid analgesics. However, this absence of efficacy seems to be driven by codeine, as opioids other than codeine are more effective than nonopioids (mostly NSAIDs). Further prospective studies on the efficacy of short-term opioid use after ED discharge (excluding codeine), measuring patient-centered outcomes, adverse events, and potential misuse, are needed.

Local colonisations and extinctions of European birds are poorly explained by changes in climate suitability.

Climate change has been associated with both latitudinal and elevational shifts in species' ranges. The extent, however, to which climate change has driven recent range shifts alongside other putative drivers remains uncertain. Here, we use the changing distributions of 378 European breeding bird species over 30 years to explore the putative drivers of recent range dynamics, considering the effects of climate, land cover, other environmental variables, and species' traits on the probability of local colonisation and extinction. On average, species shifted their ranges by 2.4 km/year. These shifts, however, were significantly different from expectations due to changing climate and land cover. We found that local colonisation and extinction events were influenced primarily by initial climate conditions and by species' range traits. By contrast, changes in climate suitability over the period were less important. This highlights the limitations of using only climate and land cover when projecting future changes in species' ranges and emphasises the need for integrative, multi-predictor approaches for more robust forecasting.

Effects of a Sleep Hygiene Strategy on Parameters of Sleep Quality and Quantity in Youth Elite Rugby Union Players.

PURPOSE: To assess the effects of a sleep hygiene strategy on parameters of sleep quality and quantity in youth elite rugby union players. METHOD: Eleven male players (age: 19.0 [1.4] y) undertook a sleep hygiene strategy composed of 2 theoretical sessions and 3 practical sessions over a 4-week period. Sleeping time, time in bed, total sleep time, sleep latency (SL), sleep efficiency (SE), wake after sleep onset, and wake bouts were recorded with an actigraphic device during the 4-week sleep hygiene strategy (baseline) and during 4 weeks after the last intervention (postintervention). RESULTS: At baseline, the overall group reported poor sleep quantity (total sleep time = 6:27 [0:30] min), but sleep quality was considered acceptable (SL = 0:18 [0:08] min and SE = 77.8% [5.8%]). Postintervention, the overall group showed a small improvement in SL (d = -0.23 [-0.42 to -0.04], P = .003) and SE (d = 0.30 [0.03 to 0.57], P = .0004). For individual responses, sleeping time, time in bed, and total sleep time were positively influenced in only 4, 3, and 5 players, respectively. For parameters of sleep quality, SL and SE were positively influenced in a majority of players (n = 7 and 8, respectively). The magnitude of difference between baseline and postintervention was strongly associated with baseline values in SE (r = -.86; P = .0005) and wake after sleep onset (r = -.87; P = .0007). CONCLUSION: A sleep hygiene strategy is efficient to improve sleep quality but not sleep quantity in young rugby union players. The strategy was more efficient in players with lower initial sleep quality and should be implemented prior to a high cumulative fatigue period.

Sleep Location and Its Association with Caregiver Sleep Quality During Patient Hospital Admission.

During acute hospitalization, many caregivers decide to stay at the care recipient's bedside over the course of several days or months, coping with a stressful situation and a poor sleeping environment. Our objective was to characterize caregiver sleep-wake cycles during care recipient hospital admission and test the association between sleep location (home versus hospital) and caregiver sleep. Eighty-six informal caregivers (78.8% female; age 55.47 ± 12.43 years) were recruited. For seven consecutive days, caregivers wore actigraphy devices and filled a sleep diary indicating whether they had slept at the hospital or at home. Caregiver insomnia symptoms, anxiety, and depression along with patient dependence were also assessed. Nighttime total sleep time, wake after sleep onset, sleep efficiency, sleep latency, and fragmentation index were described. Mixed-model analyses were used to evaluate the effect of the overnight location (home versus hospital) on caregiver sleep quality. In total, 38.4% of caregivers exhibited poor objective sleep efficiencies (< 80%), and 43% of caregivers reported having moderate to severe insomnia symptoms. Caregivers mostly slept at the hospital (n = 53), but some slept at home (n = 14) or between both locations (n = 19). Mixed-model analyses using actigraphy showed that caregivers had significantly better sleep quality when resting at home regarding wake after sleep onset, fragmentation index, and sleep efficiency (p < .05). Caregivers experienced poor sleep quality during care recipients' hospitalization, specifically when sleeping at the hospital versus sleeping at home. Healthcare workers should ensure caregivers' well-being and strongly encourage caregivers to rest at home whenever possible.

Farmland practices are driving bird population decline across Europe.

Declines in European bird populations are reported for decades but the direct effect of major anthropogenic pressures on such declines remains unquantified. Causal relationships between pressures and bird population responses are difficult to identify as pressures interact at different spatial scales and responses vary among species. Here, we uncover direct relationships between population time-series of 170 common bird species, monitored at more than 20,000 sites in 28 European countries, over 37 y, and four widespread anthropogenic pressures: agricultural intensification, change in forest cover, urbanisation and temperature change over the last decades. We quantify the influence of each pressure on population time-series and its importance relative to other pressures, and we identify traits of most affected species. We find that agricultural intensification, in particular pesticides and fertiliser use, is the main pressure for most bird population declines, especially for invertebrate feeders. Responses to changes in forest cover, urbanisation and temperature are more species-specific. Specifically, forest cover is associated with a positive effect and growing urbanisation with a negative effect on population dynamics, while temperature change has an effect on the dynamics of a large number of bird populations, the magnitude and direction of which depend on species' thermal preferences. Our results not only confirm the pervasive and strong effects of anthropogenic pressures on common breeding birds, but quantify the relative strength of these effects stressing the urgent need for transformative changes in the way of inhabiting the world in European countries, if bird populations shall have a chance of recovering.

Impact of vitamin C on the reduction of opioid consumption after an emergency department visit for acute musculoskeletal pain: a double-blind randomised control trial protocol.

INTRODUCTION: Recent evidence has shown that vitamin C has some analgesic properties in addition to its antioxidant effect and can, therefore, reduce opioid use during recovery time. Vitamin C analgesic effect has been explored mostly during short-term postoperative context or in disease-specific chronic pain prevention, but never after acute musculoskeletal injuries, which are often seen in the emergency department (ED). The protocol's primary aim is to compare the total morphine 5 mg pills consumed during a 2-week follow-up between patients receiving vitamin C or a placebo after ED discharge for an acute musculoskeletal pain complaint. METHODS AND ANALYSIS: We will conduct a two-centre double-blind randomised placebo-controlled trial with 464 participants distributed in two arms, one group receiving 1000 mg of vitamin C two times a day for 14 days and another one receiving a placebo. Participants will be ≥18 years of age, treated in ED for acute musculoskeletal pain present for less than 2 weeks and discharged with an opioid prescription for home pain management. Total morphine 5 mg pills consumed during the 2-week follow-up will be assessed via an electronic (or paper) diary. In addition, patients will report their daily pain intensity, pain relief, side effects and other types of pain medication or other non-pharmacological approach used. Three months after the injury, participants will also be contacted to evaluate chronic pain development. We hypothesised that vitamin C, compared with a placebo, will reduce opioid consumption during a 14-day follow-up for ED discharged patients treated for acute musculoskeletal pain. ETHICS AND DISSEMINATION: This study has received approval from the Ethics Review Committee from the 'Comité d'éthique de la recherche du CIUSSS du Nord-de-l'Île-de-Montréal (No 2023-2442)'. Findings will be disseminated through scientific conferences and peer-reviewed journal publication. The data sets generated during the study will be available from the corresponding author on reasonable request. TRIAL REGISTRATION NUMBER: NCT05555576 ClinicalTrials.Gov PRS.

Nocturnal sleep duration trajectories in early childhood and school performance at age 10 years.

Sleep plays a fundamental role in brain development and resultant functions. The aim was to verify whether nocturnal sleep duration during early childhood has long-term associations with academic achievement at age 10 years. The present study is part of the Quebec Longitudinal Study of Child Development, a representative cohort of infants born in 1997-1998 in the province of Quebec, Canada. Children with known neurological conditions were excluded from this cohort. Four trajectories of parent-reported nocturnal sleep duration at ages 2.5, 3, 4, 5 and 6 years were determined using a SAS procedure named PROC TRAJ. Sleep duration at age 10 years was also reported. Teachers provided data on academic performance when the children were age 10 years. These data were available for 910 children (430 boys, 480 girls; 96.6% Caucasians). Univariate and multivariable logistic regressions were performed using SPSS. Children who slept less than 8 hr per night at 2.5 years but normalized later on (Traj1) had three-five times the odds of having grades below the class average in reading, writing, mathematics and science compared with children who slept sufficiently (Traj3-4: 10-11 hr per night). Children who slept about 9 hr per night throughout childhood (Traj2) had two-three times the odds of being below the class average in mathematics and science. Sleep duration at age 10 years was not correlated with the academic performance. These results point to the presence of a very important early period during which sufficient sleep is needed to fine-tune the functions necessary for academic achievement later on.

Clinical outcomes following out-of-hospital cardiac arrest: The minute-by-minute impact of bystander cardiopulmonary resuscitation.

AIMS: The time-dependent prognostic role of bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients has not been described with great precision, especially for neurologic outcomes. Our objective was to assess the association between bystander CPR, emergency medical service (EMS) response time, and OHCA patients' outcomes. METHODS: This cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registries. Bystander-witnessed adult OHCA treated by EMS were included. The primary outcome was survival to hospital discharge and secondary outcome was survival with a good neurologic outcome (modified Rankin scale 0-2). Multivariable logistic regression models were used to assess the associations and interactions between bystander CPR, EMS response time and clinical outcomes. RESULTS: Out of 229,637 patients, 41,012 were included (18,867 [46.0%] without bystander CPR and 22,145 [54.0%] with bystander CPR). Bystander CPR was independently associated with higher survival (adjusted odds ratio [AOR] = 1.70 [95%CI 1.61-1.80]) and survival with a good neurologic outcome (AOR = 1.87 [95%CI 1.70-2.06]), while longer EMS response times were independently associated with lower survival to hospital discharge (each additional minute of EMS response time: AOR = 0.92 [95%CI 0.91-0.93], p < 0.001) and lower survival with a good neurologic outcome (AOR = 0.88 [95%CI 0.86-0.89], p < 0.001). There was no interaction between bystander CPR and EMS response time's association with survival (p = 0.12) and neurologic outcomes (p = 0.65). CONCLUSIONS: Although bystander CPR is associated with an immediate increase in odds of survival and of good neurologic outcome for OHCA patients, it does not influence the negative association between longer EMS response time and survival and good neurologic outcome.

Association of Initial Pulseless Electrical Activity Heart Rate and Clinical Outcomes following Adult Non-Traumatic Out-of-Hospital Cardiac Arrest.

OBJECTIVE: Studies evaluating the prognostic value of the pulseless electrical activity (PEA) heart rate in out-of-hospital cardiac arrest (OHCA) patients have reported conflicting results. The objective of this study was to evaluate the association between the initial PEA heart rate and favorable clinical outcomes for OHCA patients. METHODS: The present post-hoc cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry Version 3, which included OHCA patients in seven US and three Canadian sites from April 2011 to June 2015. The primary outcome was survival to hospital discharge and the secondary outcome was survival with a good functional outcome. For the primary analysis, the patients were separated into eight groups according to their first rhythms and PEA heart rates: (1) initial PEA heart rate of 1-20 beats per minute (bpm); (2) 21-40 bpm; (3) 41-60 bpm; (4) 61-80 bpm; (5) 81-100 bpm; (6) 101-120 bpm; (7) over 120 bpm; (8) initial shockable rhythm (reference category). Multivariable logistic regression models were used to assess the associations of interest. RESULTS: We identified 17,675 patients (PEA: 7,089 [40.1%]; initial shockable rhythm: 10,797 [59.9%]). Patients with initial PEA electrical frequencies ≤100 bpm were less likely to survive to hospital discharge than patients with initial shockable rhythms (1-20 bpm: adjusted odds ratio [AOR] = 0.15 [95%CI 0.11-0.21]; 21-40 bpm: AOR = 0.21 [0.18-0.25]; 41-60 bpm: AOR = 0.30 [0.25-0.36]; 61-80 bpm: AOR = 0.37 [0.28-0.49]; 81-100 bpm: AOR = 0.55 [0.41-0.65]). However, there were no statistical outcome differences between PEA patients with initial electrical frequencies of >100 bpm and patients with initial shockable rhythms (101-120 bpm: AOR = 0.65 [95%CI 0.42-1.01]; >120 bpm: AOR = 0.72 [95%CI 0.37-1.39]). Similar results were observed for survival with good functional outcomes (101-120 bpm: AOR = 0.60 [95%CI 0.31-1.15]; >120 bpm: AOR = 1.08 [95%CI 0.50-2.28]). CONCLUSIONS: We observed a good association between higher initial PEA electrical frequency and favorable clinical outcomes for OHCA patients. As there is no significant difference in outcomes between patients with initial PEA heart rates of more than 100 bpm and those with initial shockable rhythms, we can hypothesize that these patients could be considered in the same prognostic category.

Accuracy of a self-report prescription opioid use diary for patients discharge from the emergency department with acute pain: a multicentre prospective cohort study.

OBJECTIVES: Self-reported approaches that assess opioid usage can be subject to social desirability and recall biases that may underestimate actual pill consumption. Our objective was to determine the accuracy of patient self-reported opioid consumption using a 14-day daily paper or electronic diary. DESIGN: Prospective cohort study. SETTING: Multicentre study conducted in four Québec (Canada) emergency departments (ED): three university-affiliated centres, two of them Level I trauma centres and one urban community hospital. PARTICIPANTS: ED patients aged ≥18 years with acute pain (≤2 weeks) who were discharged with an opioid prescription. Patients completed a 14-day daily diary (paper or electronic) assessing the quantity of opioids consumed. On diary completion, a random sample from the main cohort was selected for a follow-up visit to the hospital or a virtual video visit where they had to show and count the remaining pills. Patients were blinded to the main objective of the follow-up visit. OUTCOMES: Quantity of opioid pills consumed during the 2-week follow-up period self-reported in the 14-day diary (paper or electronic) and calculated from remaining pills counted during the follow-up visit. Intraclass correlation coefficient (ICC) and Bland-Altman plots were used to assess accuracy. RESULTS: A total of 166 participants completed the 14-day diary as well as the in-person or virtual visit; 49.4% were women and median age was 47 years (IQR=21). The self-reported consumed quantity of opioid in the 14-day diary and the one calculated from counting remaining opioid pills during the follow-up visit were very similar (ICC=0.992; 95% CI: 0.989 to 0.994). The mean difference between both measures from Bland-Altman analysis was almost zero (0.048 pills; 95% CI: -3.77 to 3.87). CONCLUSION: Self-reported prescription opioid use in a 14-day diary is an accurate assessment of the quantity of opioids consumed in ED discharged patients. TRIAL REGISTRATION NUMBER: NCT03953534.

Impact of tapering and proactive recovery on young elite rugby union players' repeated high intensity effort ability.

To assess the effects of a taper combined with proactive recovery on the repeated high intensity effort (RHIE) of elite rugby union players, and the possible interaction of pre-taper fatigue and sleep. Eighteen players performed a 3-week intensive training block followed by a 7-day exponential taper combined with a multicomponent recovery strategy. Following the intervention, players were divided into 3 groups (Normal Training: NT, Acute Fatigue: AF or Functional Overreaching: F-OR) based on their readiness to perform prior to the taper. Total sprint time [TST], percentage decrement [%D] and the number of sprints ≥90% of the best [N90] were analyzed to assess performance during a RHIE test. Subjective sleep quality was assessed through the Pittsburg Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS). No improvement in TST was reported in either NT or F-OR after the taper, whereas AF tended to improve (-1.58 ± 1.95%; p > 0.05; g = -0.20). F-OR players reported baseline PSQI and ESS indicative of sleep disturbance (6.2 ± 2.2 and 10.6 ± 5.4, respectively). AF displayed a small impairment in PSQI during intensive training (11.5 ± 80.6%; p > 0.05; g = 0.20), which was reversed following the taper (-34.6 ± 62.1%; p > 0.05; g = -0.73). Pre-taper fatigue precluded the expected performance benefits of the combined taper and recovery intervention, likely associated with a lack of strictly controlled intensive training block. Poor sleep quality before the intensive training period appeared to predispose the players to developing functional overreaching.

Impact of operation duration on postoperative outcomes of minimally-invasive right colectomy.

AIM: Operation time (OT) is a key operational factor influencing surgical outcomes. The present study aimed to analyse whether OT impacts on short-term outcomes of minimally-invasive right colectomies by assessing the role of surgical approach (robotic [RRC] or laparoscopic right colectomy [LRC]), and type of ileocolic anastomosis (i.e., intracorporal [IA] or extra-corporal anastomosis [EA]). METHODS: This was a retrospective analysis of the Minimally-invasivE surgery for oncological Right ColectomY (MERCY) Study Group database, which included adult patients with nonmetastatic right colon adenocarcinoma operated on by oncological RRC or LRC between January 2014 and December 2020. Univariate and multivariate analyses were used. RESULTS: The study sample was composed of 1549 patients who were divided into three groups according to the OT quartiles: (1) First quartile, <135 min (n = 386); (2) Second and third quartiles, 135-199 min (n = 731); and (3) Fourth quartile ≥200 min (n = 432). The majority (62.7%) were LRC-EA, followed by LRC-IA (24.3%), RRC-IA (11.1%), and RRC-EA (1.9%). Independent predictors of an OT ≥ 200 min included male gender, age, obesity, diabetes, use of indocyanine green fluorescence, and IA confection. An OT ≥ 200 min was significantly associated with an increased risk of postoperative noninfective complications (AOR: 1.56; 95% CI: 1.15-2.13; p = 0.004), whereas the surgical approach and the type of anastomosis had no impact on postoperative morbidity. CONCLUSION: Prolonged OT is independently associated with increased odds of postoperative noninfective complications in oncological minimally-invasive right colectomy.

Accuracy of the Initial Rhythm to Predict a Short No-Flow Time in Out-of-Hospital Cardiac Arrest.

OBJECTIVES: The no-flow time (NFT) can help establish prognosis in out-of-hospital cardiac arrest (OHCA) patients. It is often used as a selection criterion for extracorporeal resuscitation. In patients with an unwitnessed OHCA for whom the NFT is unknown, the initial rhythm has been proposed to identify those more likely to have had a short NFT. Our objective was to determine the predictive accuracy of an initial shockable rhythm for an NFT of 5 minutes or less (NFT ≤ 5). DESIGN: Retrospective analysis of prospectively collected data. SETTING: Prehospital OHCA in eight U.S. and three Canadian sites. PATIENTS: A total of 28,139 adult patients with a witnessed nontraumatic OHCA were included, of whom 11,228 (39.9%) experienced an emergency medical service-witnessed OHCA (NFT = 0), 695 (2.7%) had a bystander-witnessed OHCA, and an NFT less than or equal to 5, and 16,216 (57.6%) with a bystander-witnessed OHCA and an NFT greater than 5. INTERVENTIONS: Sensitivity, specificity, and likelihood ratios of an initial shockable rhythm to identify patients with an NFT less than or equal to 5 minutes. MEASUREMENTS AND MAIN RESULTS: The sensitivity of an initial shockable rhythm to identify patients with an NFT less than or equal to 5 was poor (25% [95% CI, 25-26]), but specificity was moderate (70% [95% CI, 69-71]). The positive and likelihood ratios were inverted (negative accuracy) (positive likelihood ratio, 0.76 [95% CI, 0.74-0.79]; negative likelihood ratio, 1.12 [95% CI, 1.10-1.12]). Including only patients with a bystander-witnessed OHCA improved the sensitivity to 48% (95% CI, 45-52), the positive likelihood ratio to 1.45 (95% CI, 1.33-1.58), and the negative likelihood ratio to 0.77 (95% CI, 0.72-0.83), while slightly lowering the specificity to 67% (95% CI, 66-67). CONCLUSIONS: Our analysis demonstrated that the presence of a shockable rhythm at the time of initial assessment was poorly sensitive and only moderately specific for OHCA patients with a short NFT. The initial rhythm, therefore, should not be used as a surrogate for NFT in clinical decision-making.

Preconditioning Activities to Enhance Repeated High-Intensity Efforts in Elite Rugby Union Players.

PURPOSE: To assess the effect of a rugby-specific high-intensity interval-training (HIITRugby) protocol on the repeated high-intensity-effort ability of young elite rugby union players and to verify the influence of 2 preconditioning sequences composed either of physical contacts (ie, tackles) or of additional runs on the magnitude of improvement. METHOD: Fourteen players (19 [1] y; 183.5 [8.6] cm; 95.6 [15.6] kg) underwent an HIITRugby protocol, consisting of 7 supervised training sessions over 4 weeks, each session including 3 or 4 sets of 1 to 2 minutes with 1-minute recovery. Prior to HIITRugby training, players underwent a preconditioning contact sequence or a preconditioning running sequence, to assess their influence on subsequent interval-training sessions. RESULTS: The overall group showed a moderate improvement in total sprint time, sprints ≥90% of the best, and 20-m sprint (-3.91% [2.68%], P = .0002; 74.6% [123.7%], P = .012; -3.22% [3.13%], P = .003, respectively) and a large improvement in percentage decrement (-23.1% [20.5%], P = .005) following the 4-week training block. Relative improvements were similar between groups in total sprint time, 20-m sprint, and perceived difficulty, but the preconditioning running-sequence group exhibited a larger magnitude of gains in percentage decrement (-28.6% [20.2%] vs -17.6% [20.7%]; effect size = -1.01 vs -0.73). CONCLUSION: An HIITRugby training block was effective to improve repeated high-intensity-effort ability. A preconditioning contact sequence prior to HIITRugby can reduce subsequent long-interval running activity, which may attenuate the improvement of repeated high-intensity-effort indices related to the aerobic system.

Evaluation of Interventions to Reduce Opioid Prescribing for Patients Discharged From the Emergency Department: A Systematic Review and Meta-analysis.

Importance: Limiting opioid overprescribing in the emergency department (ED) may be associated with decreases in diversion and misuse. Objective: To review and analyze interventions designed to reduce the rate of opioid prescriptions or the quantity prescribed for pain in adults discharged from the ED. Data Sources: MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Controlled Register of Trials databases and the gray literature were searched from inception to May 15, 2020, with an updated search performed March 6, 2021. Study Selection: Intervention studies aimed at reducing opioid prescribing at ED discharge were first screened using titles and abstracts. The full text of the remaining citations was then evaluated against inclusion and exclusion criteria by 2 independent reviewers. Data Extraction and Synthesis: Data were extracted independently by 2 reviewers who also assessed the risk of bias. Authors were contacted for missing data. The main meta-analysis was accompanied by intervention category subgroup analyses. All meta-analyses used random-effects models, and heterogeneity was quantified using I2 values. Main Outcomes and Measures: The primary outcome was the variation in opioid prescription rate and/or prescribed quantity associated with the interventions. Effect sizes were computed separately for interrupted time series (ITS) studies. Results: Sixty-three unique studies were included in the review, and 45 studies had sufficient data to be included in the meta-analysis. A statistically significant reduction in the opioid prescription rate was observed for both ITS (6-month step change, -22.61%; 95% CI, -30.70% to -14.52%) and other (odds ratio, 0.56; 95% CI, 0.45-0.70) study designs. No statistically significant reduction in prescribed opioid quantities was observed for ITS studies (6-month step change, -8.64%; 95% CI, -17.48% to 0.20%), but a small, statistically significant reduction was observed for other study designs (standardized mean difference, -0.30; 95% CI, -0.51 to -0.09). For ITS studies, education, policies, and guideline interventions (6-month step change, -33.31%; 95% CI, -39.67% to -26.94%) were better at reducing the opioid prescription rate compared with prescription drug monitoring programs and laws (6-month step change, -11.18%; 95% CI, -22.34% to -0.03%). Most intervention categories did not reduce prescribed opioid quantities. Insufficient data were available on patient-centered outcomes such as pain relief or patients' satisfaction. Conclusions and Relevance: This systematic review and meta-analysis found that most interventions reduced the opioid prescription rate but not the prescribed opioid quantity for ED-discharged patients. More studies on patient-centered outcomes and using novel approaches to reduce the opioid quantity per prescription are needed. Trial Registration: PROSPERO Identifier: CRD42020187251.

Association between fentanyl treatment for acute pain in the emergency department and opioid use two weeks after discharge.

BACKGROUND: Analgesia with fentanyl can be associated with hyperalgesia (higher sensitivity to pain) and can contribute to escalating opioid use. Our objective was to assess the relationship between emergency department (ED) acute pain management with fentanyl compared to other opioids, and the quantity of opioids consumed two-week after discharge. We hypothesized that the quantity of opioids consumed would be higher for patients treated with fentanyl compared to those treated with other opioids. METHODS: Patients were selected from two prospective cohorts assessing opioids consumed after ED discharge. Patients ≥18 years treated with an opioid in the ED for an acute pain condition (≤2 weeks) and discharged with an opioid prescription were included. Patients completed a 14-day paper or electronic diary of pain medication use. Quantity of 5 mg morphine equivalent tablets consumed during a 14-day follow-up by patients treated with fentanyl compared to those treated with other opioids during their ED stay were analyzed using a multiple linear regression and propensity scores. RESULTS: We included 707 patients (mean age ± SD: 50 ± 15 years, 47% women) in this study. During follow-up, patients treated with fentanyl (N = 91) during their ED stay consumed a median (IQR) of 5.8 (14) 5 mg morphine equivalent pills compared to 7.0 (14) for those treated with other opioids (p = 0.05). Results were similar using propensity score sensitivity analysis. However, after adjusting for confounding variables, ED fentanyl treatment showed a trend, but not a statistically significant association with a decreased opioid consumption during the 14-day follow-up (B = -2.4; 95%CI = -5.3 to 0.4; p = 0.09). CONCLUSIONS: Patients treated with fentanyl during ED stay did not consume more opioids after ED discharge, compared to those treated with other opioids. If fentanyl does cause more hyperalgesia compared to other opioids, it does not seem to have a significant impact on opioid consumption after ED discharge.

Protected area characteristics that help waterbirds respond to climate warming.

Protected area networks help species respond to climate warming. However, the contribution of a site's environmental and conservation-relevant characteristics to these responses is not well understood. We investigated how composition of nonbreeding waterbird communities (97 species) in the European Union Natura 2000 (N2K) network (3018 sites) changed in response to increases in temperature over 25 years in 26 European countries. We measured community reshuffling based on abundance time series collected under the International Waterbird Census relative to N2K sites' conservation targets, funding, designation period, and management plan status. Waterbird community composition in sites explicitly designated to protect them and with management plans changed more quickly in response to climate warming than in other N2K sites. Temporal community changes were not affected by the designation period despite greater exposure to temperature increase inside late-designated N2K sites. Sites funded under the LIFE program had lower climate-driven community changes than sites that did not received LIFE funding. Our findings imply that efficient conservation policy that helps waterbird communities respond to climate warming is associated with sites specifically managed for waterbirds.

Las redes de áreas protegidas ayudan a las especies a responder al calentamiento climático. Sin embargo, se sabe muy poco sobre la contribución de las características ambientales y relevantes para la conservación de un sitio a estas respuestas. Investigamos cómo la composición de las comunidades no reproductivas de aves acuáticas (97 especies) en la red (3,018 sitios) Natura 2000 de la Unión Europea (N2K) cambió en respuesta a los incrementos de la temperatura durante más de 25 años en 26 países europeos. Medimos la reorganización comunitaria con base en series temporales de abundancia recolectadas durante el Censo Internacional de Aves Acuáticas en relación con los objetivos de conservación de los sitios N2K, el periodo de asignación de fondos y el estado del plan de manejo. La composición comunitaria de las aves acuáticas en los sitios con planes de manejo y designados explícitamente para su protección cambió más rápidamente en respuesta al calentamiento climático que en otros sitios N2K. Los cambios comunitarios temporales no se vieron afectados por el periodo de asignación a pesar de una mayor exposición al incremento de la temperatura dentro de los sitios N2K de asignación tardía. Los sitios financiados por el programa LIFE tuvieron menos cambios comunitarios causados por el clima que los sitios que no recibieron este financiamiento. Nuestros hallazgos sugieren que la política de conservación eficiente que ayuda a las comunidades de aves acuáticas a responder al calentamiento climático está asociada con sitios específicamente gestionados para las aves acuáticas.

Electrical rhythm degeneration in adults with out-of-hospital cardiac arrest according to the no-flow and bystander low-flow time.

AIMS: For out-of-hospital cardiac arrest (OHCA) patients, the influence of the delay before the initiation of resuscitation, termed the no-flow time (NFT), and duration of bystander-only resuscitation low-flow time (BLFT) on the type of electrical rhythm observed has not been well described. The objective of this study is to determine the relationship between NFT, BLFT and the likelihood of a shockable rhythm over time. METHODS: Using a North American prospective registry (2005-2015; mostly urban settings), we selected adult (18 years and over) patients who experienced a witnessed OHCA from a suspected cardiac etiology. Patients with an emergency medical services witnessed OHCA were only included in sensitivity analyses. The association between the NFT, BLFT and the presence of a shockable rhythm was evaluated using a multivariable logistic regression adjusting for the registry version, age, sex, and public location. RESULTS: A total of 229,632 patients were logged in the registry, 50,957 of whom were included. Of these, 17,704 (34.7%) had an initial shockable rhythm. After the first minute, a significant decrease over time in the occurrence of shockable rhythm is observed but is slower when bystander cardiopulmonary resuscitation (CPR) is provided (each supplemental minute of BLFT: adjusted odds ratio = 0.95, 95 %CI = 0.94-0.95; each supplemental minute of NFT: adjusted odds ratio = 0.91, 95 %CI = 0.90-0.91]). CONCLUSIONS: In this large observational study, we were able to demonstrate that longer NFT were associated with lower odds of shockable presenting rhythms. Bystander CPR significantly mitigates the degradation of shockable rhythms over time, strengthening the need to improve bystander CPR rates around the world.

Opioid and non-opioid pain relief after an emergency department acute pain visit.

OBJECTIVES: Treatment of acute pain after emergency department (ED) discharge remains a challenge in the opioid crisis context. Our objective was to determine the proportion of patients using opioid vs non-opioid pain medication following discharge from the ED with acute pain, and the association of type of pain medication with average pain intensity before pain medication intake and report of pain relief. METHODS: This was a prospective cohort study of ED patients aged ≥ 18 years with an acute pain (≤ 2 weeks) who were discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain intensity level before each pain medication intake (0-10 numeric rating scale), type of pain medication use (opioid vs non-opioid), and if pain was relieved by the medication used that day. Multilevel analyses were used to compare the effect of type of analgesic used on pain intensity and relief. RESULTS: A total of 381 participants completed the 14-day diary; 50% were women and median age was 54 years (IQR = 43-66). Average daily pain intensity before pain medication intake was significantly higher for patients who used opioids (5.9; 95% CI 5.7-6.2) as compared to non-opioid analgesics (4.2; 95% CI 4.0-4.5) or no pain medication (2.2; 95% CI 1.9-2.5). Controlling for pain intensity, patients using opioids were more likely to report a pain relief (OR = 1.3; 95% CI 1.1-1.8) as compared to those who used non-opioid analgesics. CONCLUSION: Overall, opioids appear to be effective and used as intended by the prescribing physician.

RéSUMé: OBJECTIFS: Le traitement de la douleur aiguë après la sortie des départements d'urgence (DU) reste un défi dans le contexte de la crise des opioïdes. Notre objectif était de déterminer la proportion de patients utilisant des analgésiques opioïdes par rapport aux analgésiques non opioïdes après leur sortie des urgences avec une douleur aiguë, et l'association du type d'analgésique avec l'intensité moyenne de la douleur avant la prise d'analgésiques et le soulagement de la douleur rapporté. LES MéTHODES: Il s'agissait d'une étude de cohorte prospective de patients (DU) âgés de ≥18 ans souffrant de douleurs aiguës (≤ 2 semaines) et ayant reçu une ordonnance d'opioïdes à leur sortie de l'hôpital. Les patients ont rempli un journal de 14 jours évaluant le niveau d'intensité de la douleur quotidienne avant chaque prise de médicaments anti-douleur (échelle d'évaluation numérique de 0 à 10), le type d'utilisation des médicaments anti-douleur (opioïdes contre non opioïdes), et si la douleur était soulagée par les médicaments utilisés ce jour-là. Des analyses multiniveaux ont été utilisées pour comparer l'effet du type d'analgésique utilisé sur l'intensité et le soulagement de la douleur. RéSULTATS: Au total, 381 participants ont rempli le journal de 14 jours; 50% étaient des femmes et l'âge médian était de 54 ans (EI = 43­66). L'intensité moyenne de la douleur quotidienne avant la prise d'analgésiques était significativement plus élevée chez les patients qui prenaient des opioïdes (5.9; 95% IC: 5.7­6.2) par rapport aux analgésiques non opioïdes (4.2; 95% IC: 4.0­4.5) ou à l'absence d'analgésiques (2.2; 95% IC: 1.9­2.5). En contrôlant l'intensité de la douleur, les patients utilisant des opioïdes étaient plus susceptibles de déclarer un soulagement de la douleur (OR = 1.3; 95% CI: 1.1−1.8) par rapport à ceux qui utilisaient des analgésiques non opioïdes. CONCLUSION: Dans l'ensemble, les opioïdes semblent être efficaces et utilisés comme prévu par le médecin prescripteur.