Intravenous acetaminophen does not have an opioid sparing effect in Emergency Department patients with painful conditions.

BACKGROUND: Pain in the Emergency Department is common and is frequently treated with opioids. Due to the opioid epidemic, it is clinically helpful to decrease opioid usage. The purpose of this study was to evaluate opioid requirement in Emergency Department patients with painful conditions who receive intravenous acetaminophen. METHODS: In this prospective cohort study, patients aged 18 years and older and treated with opioids in the acute phase were included. Patients receiving additional intravenous acetaminophen were compared to patients who did not. Primary outcome was opioid requirement, measured in Morphine Equivalent Units (MEU) during Emergency Department stay. Secondary outcomes were opioid requirement after discharge; decrease in pain scores; occurrence of adverse events and patient satisfaction. RESULTS: A total of 116 patients were included of whom 76 received intravenous acetaminophen. Opioid consumption in the acute phase was not significantly different (p=0.53) between patients receiving (10.0 MEU (IQR 7.5; 15.0)) and those not receiving acetaminophen: 10.0 MEU (IQR 7.1; 15.0). After discharge these numbers were 15.0 MEU (IQR 7.5; 30.0) versus 30.0 MEU (IQR 15.0; 43.8), respectively (p=0.059). In both groups median NRS pain scores decreased from 9.0 to 4.0 and >80% of patients were satisfied regarding pain treatment. Nine minor adverse events were recorded, equally divided among the groups. CONCLUSIONS: The additional use of intravenous acetaminophen did not decrease opioid requirement in adult patients with acute pain during Emergency Department stay. There was a trend towards decreased opioid requirement during 24 h after discharge.

BCG scarring and improved child survival: a combined analysis of studies of BCG scarring.

Bacillus Calmette-Guérin (BCG) vaccine against tuberculosis (TB) is recommended at birth in TB-endemic areas. Currently, BCG vaccination programmes use "BCG vaccination coverage by 12 months of age" as the performance indicator. Previous studies suggest that BCG-vaccinated children, who develop a scar, have better overall survival compared with BCG-vaccinated children, who do not develop a scar. We summarized the available studies of BCG scarring and child survival. A structured literature search for studies with original data and analysis of BCG scarring and mortality were performed. Combined analyses on the effect of BCG scarring on overall mortality. We identified six studies covering seven cohorts, all from Guinea-Bissau, West Africa, with evaluation of BCG scarring amongst BCG-vaccinated children and follow-up for mortality. Determinants of BCG scarring were BCG strain, intradermal injection route, size of injection wheal, and co-administered vaccines and micronutrients. In a combined analysis, having a BCG scar vs. no BCG scar was associated with a mortality rate ratio (MRR) of 0.61 (95% CI: 0.51-0.74). The proportion with a BCG scar varied from 52 to 93%; the estimated effect of a BCG scar was not associated with the scar prevalence. The effect was strongest in the first (MRR = 0.48 (0.37-0.62)) and second (MRR = 0.63 (0.44-0.92)) year of life, and in children BCG-vaccinated in the neonatal period (MRR = 0.45 (0.36-0.55)). The effect was not explained by protection against TB. Confounding and genetic factors are unlikely to explain the strong association between BCG scarring and subsequent survival. Including "BCG scar prevalence" as a BCG vaccination programme performance indicator should be considered. The effect of revaccinating scar-negative children should be studied.

Review of antireflux procedures for proton pump inhibitor nonresponsive gastroesophageal reflux disease.

Up to 40% of patients with gastroesophageal reflux disease (GERD) report persistent symptoms despite proton pump inhibitor (PPI) therapy. This review outlines the evidence for surgical and endoscopic therapies for the treatment of PPI nonresponsive GERD. A literature search for GERD therapies from 2005 to 2015 in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews identified 2928 unique citations. Of those, 45 unique articles specific to surgical and endoscopic therapies for PPI nonresponsive GERD were reviewed. Laparoscopic fundoplication (n = 19) provides symptomatic and physiologic relief out to 10 years, though efficacy wanes with time. Magnetic sphincter augmentation (n = 6) and transoral incisionless fundoplication (n = 9) improve symptoms in PPI nonresponders and may offer fewer side effects than fundoplication, though long-term follow-up is lacking. Radiofrequency energy delivery (n = 8) has insufficient evidence for routine use in treating PPI nonresponsive GERD. Electrical stimulator implantation (n = 1) and endoscopic mucosal surgery (n = 2) are newer therapies under evaluation for the treatment of GERD. Laparoscopic fundoplication remains the most proven therapeutic approach. Newer antireflux procedures such as magnetic sphincter augmentation and transoral incisionless fundoplication offer alternatives with varying degrees of success, durability, and side effect profiles that may better suit individual patients. Larger head-to-head comparison trials are needed to better characterize the difference in symptom response and side effect profiles.

A review of medical therapy for proton pump inhibitor nonresponsive gastroesophageal reflux disease.

Up to 40% of patients report persistent gastroesophageal reflux disease (GERD) symptoms despite proton pump inhibitor (PPI) therapy. This review outlines the evidence for medical therapy for PPI nonresponsive GERD. A literature search for GERD therapies from 2005 to 2015 in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews identified 2928 unique citations. Of those, 40 unique articles specific to the impact of PPI metabolizer genotype on PPI response and the use adjunctive medical therapies were identified. Thirteen articles reported impacts on CYP genotypes on PPI metabolism demonstrating lower endoscopic healing rates in extensive metabolizers; however, outcomes across genotypes were more uniform with more CYP independent PPIs rabeprazole and esomeprazole. Twenty-seven publications on 11 adjunctive medications showed mixed results for adjunctive therapies including nocturnal histamine-2 receptor antagonists, promotility agents, transient lower esophageal sphincter relaxation inhibitors, and mucosal protective agents. Utilizing PPI metabolizer genotype or switching to a CYP2C19 independent PPI is a simple and conservative measure that may be useful in the setting of incomplete acid suppression. The use of adjunctive medications can be considered particularly when the physiologic mechanism for PPI nonresponse is suspected. Future studies using adjunctive medications with improved study design and patient enrollment are needed to better delineate medical management options before proceeding to antireflux interventions.

[Treatment compliance]. / Therapietrouw.

The main aim of this article is to identify those factors that affect treatment compliance, the extent to which the owners of patients comply with the treatment regimen, and how to improve compliance. The article is mainly based on reports from the medical literature. Although compliance can be measured in several ways, there is no valid and reliable method. For this reason, several methods should be used. Factors that affect treatment compliance in human medicine are (I) the expected effectiveness of treatment, (II) the severity of the disorder, (III) the risks associated with medicine use, (IV) the duration and dosage of medical therapy, (V) patient motivation, and (VI) the doctor-patient relationship. In the literature, in veterinary medicine treatment compliance is reported to range from 44% to 55%, whereas in human medicine it is reported to range from 5% to 96%. Compliance can be improved if (I) the owner can easily incorporate the treatment regimen in his/her daily life, (II) the treatment regimen does not disrupt the owner's daily routine, (III) the owner is informed about and understands the treatment provided, and (IV) the relationship between veterinarian and owner is good. In conclusion, many questions about treatment compliance in veterinary medicine remain unanswered, and research is needed to answer them.