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1.
Medicine (Baltimore) ; 99(33): e21670, 2020 Aug 14.
Artigo em Inglês | MEDLINE | ID: mdl-32872033

RESUMO

BACKGROUND: Total knee arthroplasty (TKA) is an established and successful surgical procedure which is the major treatment for degenerative knee joint diseases. A novel technique to address posterior knee joint pain is the infiltration of local anesthetic between the interspace between the popliteal artery and capsule of the knee (IPACK). The goal of this randomized clinical trial was to assess the efficacy and safety of adding IPACK to adductor canal block (ACB) after TKA. METHODS: This was a prospectively randomized trial that investigated the effectiveness and safety of the IPACK after TKA. Approval from Clinical Studies Ethical Committee in Qilu Hospital of Shandong University was obtained. The inclusion criteria were adult patients undergoing primary unilateral TKA and American Society of Anesthesiologists grade 1 or 2 with normal cognitive function. The patients were randomized to 1 of 2 treatment options: ACB-alone group and ACB + IPACK group. The primary outcome was the total morphine consumption during postoperative 24 hours. Secondary outcomes included postoperative pain score, time to first and total dosage of rescue morphine in postoperative 48 hours, early and late postoperative period (from postoperative day 0-3 months follow-up) performance-based test (Timed-Up and Go test, and quadriceps strength). Postoperative nausea and vomiting, length of hospital stay, patient satisfaction, and other adverse events were also evaluated. RESULTS: It was hypothesized that when combined with a control group, the IPACK block would result in a lower morphine consumption and pain score after TKA. TRIAL REGISTRATION: This study protocol was registered in Research Registry (researchregistry5765).


Assuntos
Artroplastia do Joelho/métodos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Analgésicos Opioides/administração & dosagem , Anestésicos Locais/administração & dosagem , Humanos , Morfina/administração & dosagem , Artéria Poplítea , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Método Simples-Cego
2.
J Opioid Manag ; 16(4): 237-238, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32886349

RESUMO

The COVID-19 ARDS appears to have worse outcomes than ARDS from other causes. It is a predictable serious complication and the key strategy is to maintain oxygenation. Adopting the prone position for conscious COVID-19 patients requiring basic respiratory support, is shown to benefit patients in terms of improving oxygenation, reducing the need for invasive ventilation and potentially even reducing mortality. Cough and myalgia are the common and most distressing symptoms seen in conscious COVID-19 patients which can impair tolerance to awake proning. Modified awake proning with application of transdermal fentanyl patch (TFP) can improve the compliance to conscious proning in COVID-19 patients.


Assuntos
Analgésicos Opioides/administração & dosagem , Estado de Consciência , Infecções por Coronavirus/terapia , Fentanila/administração & dosagem , Pneumonia Viral/terapia , Decúbito Ventral , Betacoronavirus , Humanos , Pandemias , Síndrome do Desconforto Respiratório do Adulto/terapia , Síndrome do Desconforto Respiratório do Adulto/virologia , Adesivo Transdérmico
3.
Medicine (Baltimore) ; 99(36): e21971, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32899035

RESUMO

BACKGROUND: The purpose of this meta-analysis was to comprehensively collect randomized controlled trials (RCTs) to assess the clinical efficacy of intrathecal morphine (ITM) versus local infiltration analgesia (LIA) in the treatment of total knee and hip arthroplasty patients. METHODS: Relevant studies were identified from the Embase, PubMed, Cochrane Library, Web of Science, Wanfang, and Chinese National Knowledge Infrastructure (CNKI) databases. We also reviewed the references of all identified articles to identify additional studies. For each study, we assessed the risk ratio (RR), weighted mean difference (WMD), and corresponding 95% confidence interval (95% CI) to synthesize outcomes. Meta-analysis was performed with Stata 12.0 software. RESULTS: We included 13 studies with 942 patients for meta-analysis. LIA significantly decreased the pain value with rest or mobilization until 72 hours (P < .05). LIA significantly decreased cumulative morphine consumption by 13.52 mg. Moreover, the length of hospital stay was lower in the LIA group than in the ITM analgesia group. Finally, LIA significantly reduced morphine-related complications (nausea and vomiting, pruritus, and respiration depression). CONCLUSIONS: LIA was an effective approach for relieving postoperative pain and reducing postoperative consumption of morphine compared with ITM in total knee and hip arthroplasty patients.


Assuntos
Analgesia/métodos , Analgésicos Opioides/administração & dosagem , Artroplastia de Quadril , Artroplastia do Joelho , Morfina/administração & dosagem , Anestesia Local , Humanos , Injeções Espinhais , Tempo de Internação , Dor Pós-Operatória/prevenção & controle
4.
Medicine (Baltimore) ; 99(37): e21956, 2020 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-32925729

RESUMO

BACKGROUND: Several studies reported short-term analgesic efficacy of obturator nerve block (ONB), as in comparison with the femoral nerve block (FNB) in the treatment of postoperative pain after the total knee replacement (TKR). The optimal method remains under debate. The purpose of our current work is to compare the safety and efficacy of FNB and ONB for postoperative analgesia after TKR. METHODS: This prospective, randomized, and controlled study was performed from January 2018 to December 2019. It was authorized via the Institutional Review Committee in NO.971 Hospital of the People's Liberation Army Navy (2019-PLAN-132).Two hundred patients were divided randomly into 2 groups, the control group (n = 100) and study group (n = 100). The experimental group received FNB and control groups received ONB. Primary outcome included pain at different time point (Visual Analogue Scale score of anterior knee pain at rest and in motion). The Visual Analogue Scale scores were marked by patients themselves on a paper with a graduated line starting at 0 (no pain) and ending at 10 (the most painful). Opioid consumption was converted to equivalents of oral morphine uniformly for statistical analysis. Secondary outcomes included the knee range of motion, the hospital stay length as well as the postoperative complications such as pulmonary embolism and deep vein thrombosis. RESULTS: Table 1 will show the clinical outcomes between the 2 groups. CONCLUSION: This trial would provide an evidence for the use of different types of peripheral nerve blocks in TKR.


Assuntos
Artroplastia do Joelho/efeitos adversos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Administração Oral , Analgésicos Opioides/administração & dosagem , Nervo Femoral , Humanos , Pessoa de Meia-Idade , Morfina/administração & dosagem , Debilidade Muscular/etiologia , Bloqueio Nervoso/efeitos adversos , Nervo Obturador , Manejo da Dor/métodos , Medição da Dor , Complicações Pós-Operatórias , Estudos Prospectivos , Músculo Quadríceps
5.
Medicine (Baltimore) ; 99(37): e22158, 2020 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-32925776

RESUMO

BACKGROUND: Pain management after the total joint arthroplasty is still challenging, but worthy of attention, because good pain management can improve the outcomes of patient. It is still controversial whether fascia iliaca compartment block (FICB) can effectively decrease the opioid consumption and pain after total hip replacement (THR) owing to the number of published investigations is small. The purpose of this present study is to assess the efficacy and safety of FICB for postoperative analgesia after THR. METHODS: This is a single center, placebo-controlled randomized trial which is performed in accordance with the SPIRIT Checklist for randomized studies. It was authorized via the Chifeng Municipal Hospital institutional review committee (H2020-19-8). 100 patients undergoing THR will be included in this study. Patients are randomly divided into 2 groups: FICB group or Non-FICB group, FICB with 5mgmL of epinephrine and 40 mL of ropivacaine 0.2%. Primary outcomes are pain score at different time point. Visual analog scale is used to assess the pain (10: the maximum possible pain and 0: absent pain). The secondary outcomes are the postoperative complications, length of hospital stay and total consumption of opioid. All the needed analyses are implemented through utilizing SPSS for Windows Version 15.0. RESULTS: Figure 1 will show the primary and secondary outcomes. CONCLUSION: This trial can provide an evidence for the use of FICB for analgesia after THR.


Assuntos
Artroplastia de Quadril/métodos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Analgésicos Opioides/administração & dosagem , Artroplastia de Quadril/efeitos adversos , Epinefrina/administração & dosagem , Humanos , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Ropivacaina/administração & dosagem
6.
Medicine (Baltimore) ; 99(39): e22394, 2020 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-32991462

RESUMO

OBJECTIVE: We perform this protocol for randomized controlled trial to compare the efficacy of intrathecal morphine and local infiltration anesthesia (LIA) in the treatment of the postoperative pain after total knee replacement (TKR). METHODS: This is a randomized controlled, single center trial which was performed from March 2019 to March 2020. This trial is conducted according to the SPIRIT Checklist of randomized researches. It is authorized via the Ethics Committee of Beijing Friendship Hospital (2019-P2-050-01). Eighty participants who undergo TKR were randomized into 2 groups. Intrathecal morphine group: 0.1 mg of the morphine was intrathecally injected, and the spinal anesthetic was injected at the same time in the group LIA; In the LIA group: the knee joint was infiltrated with epinephrine, ketorologic acid and ropivacaine in the process of operation, and the identical mixture was injected 2 bolus through the intraarticular catheter after operation. The main outcome variables were the visual analog scale and the consumption amount of opioid every 6-hour interval within 2 days postoperatively. The secondary outcome variables were the side effects associated with opioid, the length of hospital stay, motion range, and the loss of blood collected by the closed suction drainage. All the required analyses were carried out via applying the SPSS for Windows Version 19.0. RESULTS: The clinical outcome variables between groups were shown in . CONCLUSION: This protocol will provide the evidence on which technique can achieve better analgesia after TKR.


Assuntos
Analgésicos Opioides/administração & dosagem , Anestesia Local , Artroplastia do Joelho/efeitos adversos , Morfina/administração & dosagem , Dor Pós-Operatória/prevenção & controle , Humanos , Injeções Espinhais , Dor Pós-Operatória/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto
7.
Cochrane Database Syst Rev ; 8: CD007789, 2020 08 12.
Artigo em Inglês | MEDLINE | ID: mdl-32797734

RESUMO

BACKGROUND: Acute soft tissue injuries are common and costly. The best drug treatment for such injuries is not certain, although non-steroidal anti-inflammatory drugs (NSAIDs) are often recommended. There is concern about the use of oral opioids for acute pain leading to dependence. This is an update of a Cochrane Review published in 2015. OBJECTIVES: To assess the benefits or harms of NSAIDs compared with other oral analgesics for treating acute soft tissue injuries. SEARCH METHODS: We searched the CENTRAL, 2020 Issue 1, MEDLINE (from 1946), and Embase (from 1980) to January 2020; other databases were searched to February 2019. SELECTION CRITERIA: We included randomised or quasi-randomised controlled trials involving people with acute soft tissue injury (sprain, strain, or contusion of a joint, ligament, tendon, or muscle occurring within 48 hours of inclusion in the study), and comparing oral NSAIDs versus paracetamol (acetaminophen), opioid, paracetamol plus opioid, or complementary and alternative medicine. The outcomes were pain, swelling, function, adverse effects, and early re-injury. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for eligibility, extracted data, and assessed risk of bias. We assessed the quality of the evidence using GRADE methodology. MAIN RESULTS: We included 20 studies, with 3305 participants. Three studies included children only. The others included predominantly young adults; approximately 60% were male. Seven studies recruited people with ankle sprains only. Most studies were at low or unclear risk of bias; however, two were at high risk of selection bias, three were at high risk of bias from lack of blinding, and five were at high risk of selective outcome reporting bias. Some evidence relating to pain relief was high certainty. Other evidence was either moderate, low or very low certainty, reflecting study limitations, indirectness, imprecision, or combinations of these. Thus, we are certain or moderately certain about some of the estimates, and uncertain or very uncertain of others. Eleven studies, involving 1853 participants compared NSAIDs with paracetamol. There were no differences between the two groups in pain at one to two hours (1178 participants, 6 studies; high-certainty evidence), at days one to three (1232 participants, 6 studies; high-certainty evidence), and at day seven or later (467 participants, 4 studies; low-certainty evidence). There was little difference between the groups in numbers of participants with minimal swelling at day seven or later (77 participants, 1 study; low-certainty evidence). Very low-certainty evidence from three studies (386 participants) means we are uncertain of the finding of little difference between the two groups in return to function at day seven or later. There was low-certainty evidence from 10 studies (1504 participants) that NSAIDs may slightly increase the risk of gastrointestinal adverse events compared with paracetamol. There was low-certainty evidence from nine studies (1679 participants) of little difference in neurological adverse events between the NSAID and paracetamol groups. Six studies, involving 1212 participants compared NSAIDs with opioids. There was moderate-certainty evidence of no difference between the groups in pain at one hour (1058 participants, 4 studies), and low-certainty evidence for no difference in pain at days four or seven (706 participants, 1 study). There was very low-certainty evidence of no important difference between the groups in swelling (84 participants, 1 study). Participants in the NSAIDs group were more likely to return to function in 7 to 10 days (542 participants, 2 studies; low-certainty evidence). There was moderate-certainty evidence (1143 participants, 5 studies) that NSAIDs were less likely to result in gastrointestinal or neurological adverse events compared with opioids. Four studies, involving 240 participants, compared NSAIDs with the combination of paracetamol and an opioid. The applicability of findings from these studies is in question because the dextropropoxyphene combination analgesic agents used are no longer in general use. Very low-certainty evidence means we are uncertain of the findings of no differences between the two interventions in the numbers with little or no pain at day one (51 participants, 1 study), day three (149 participants, 2 studies), or day seven (138 participants, 2 studies); swelling (230 participants, 3 studies); return to function at day seven (89 participants, 1 study); and the risk of gastrointestinal or neurological adverse events (141 participants, 3 studies). No studies reported re-injury rates. No studies compared NSAIDs with oral complementary and alternative medicines, AUTHORS' CONCLUSIONS: Compared with paracetamol, NSAIDs make no difference to pain at one to two hours and at two to three days, and may make no difference at day seven or beyond. NSAIDs may result in a small increase in gastrointestinal adverse events and may make no difference in neurological adverse events compared with paracetamol. Compared with opioids, NSAIDs probably make no difference to pain at one hour, and may make no difference at days four or seven. NSAIDs probably result in fewer gastrointestinal and neurological adverse effects compared with opioids. The very low-certainly evidence for all outcomes for the NSAIDs versus paracetamol with opioid combination analgesics means we are uncertain of the findings of no differences in pain or adverse effects. The current evidence should not be extrapolated to adults older than 65 years, as this group was not well represented in the studies.


Assuntos
Analgésicos/administração & dosagem , Anti-Inflamatórios não Esteroides/administração & dosagem , Contusões/tratamento farmacológico , Lesões dos Tecidos Moles/tratamento farmacológico , Entorses e Distensões/tratamento farmacológico , Acetaminofen/administração & dosagem , Acetaminofen/efeitos adversos , Doença Aguda , Administração Oral , Adulto , Analgésicos/efeitos adversos , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Anti-Inflamatórios não Esteroides/efeitos adversos , Viés , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como Assunto , Tempo para o Tratamento , Adulto Jovem
8.
Med Care ; 58 Suppl 2 9S: S88-S93, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826777

RESUMO

OBJECTIVES: Nonpharmacological options to treat pain are in demand, in part to address the opioid crisis. One such option is acupuncture. Battlefield acupuncture (BFA) is an auricular needling protocol currently used to treat pain in the Veterans Health Administration. We aimed to identify the advantages and disadvantages of BFA from providers' perspectives. METHODS: We rely on an inductive qualitative approach to explore provider perceptions through thematic analysis of semistructured interviews with 43 BFA providers across the nation. RESULTS: We identified the following themes. Disadvantages included: (1) clinical guidelines are insufficient; (2) patients often request multiple BFA visits from providers; (3) BFA can be uncomfortable; (4) BFA may not be an effective treatment option unless it can be provided "on demand"; and (5) BFA can promote euphoria, which can have deleterious consequences for patient self-care. Perceived advantages included: (1) BFA can simultaneously effectively control pain while reducing opioid use; (2) BFA may alleviate the pain that has been unsuccessfully treated by conventional methods; (3) BFA gives providers a treatment option to offer patients with substance use disorder; (4) BFA helps build a trusting patient-provider relationship; (5) BFA can create the opportunity for hope. CONCLUSIONS: Providers perceive BFA to have many benefits, both clinical and relational, including ways in which it may have utility in addressing the current opioid crisis. BFA is easy to deliver and has potential clinical and relational utility. Efforts to better understand effectiveness are warranted.


Assuntos
Acupuntura Auricular/métodos , Atitude do Pessoal de Saúde , Manejo da Dor/métodos , Acupuntura Auricular/efeitos adversos , Analgésicos Opioides/administração & dosagem , Protocolos Clínicos , Euforia/fisiologia , Feminino , Humanos , Masculino , Guias de Prática Clínica como Assunto , Pesquisa Qualitativa , Qualidade de Vida , Autogestão/métodos , Autogestão/psicologia , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Fatores de Tempo , Saúde dos Veteranos
9.
Med Care ; 58 Suppl 2 9S: S101-S107, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826779

RESUMO

OBJECTIVES: Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective. RESEARCH DESIGN: In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information. METHODS: A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record. RESULTS: More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was -2.5 points (SD=2.2) at the initial BFA treatment, and -2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids. CONCLUSION: VHA's rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.


Assuntos
Acupuntura Auricular/métodos , Dor Crônica/terapia , Veteranos , Acupuntura Auricular/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/administração & dosagem , Estudos de Coortes , Comorbidade , Estudos Transversais , Feminino , Nível de Saúde , Humanos , Masculino , Saúde Mental , Pessoa de Meia-Idade , Medição da Dor , Estudos Retrospectivos , Fatores Socioeconômicos , Estados Unidos , United States Department of Veterans Affairs/organização & administração , Saúde dos Veteranos , Adulto Jovem
10.
Med Care ; 58 Suppl 2 9S: S116-S124, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826781

RESUMO

BACKGROUND: Long-term opioid therapy for chronic pain arose amid limited availability and awareness of other pain therapies. Although many complementary and integrative health (CIH) and nondrug therapies are effective for chronic pain, little is known about CIH/nondrug therapy use patterns among people prescribed opioid analgesics. OBJECTIVE: The objective of this study was to estimate patterns and predictors of self-reported CIH/nondrug therapy use for chronic pain within a representative national sample of US military veterans prescribed long-term opioids for chronic pain. RESEARCH DESIGN: National two-stage stratified random sample survey combined with electronic medical record data. Data were analyzed using logistic regressions and latent class analysis. SUBJECTS: US military veterans in Veterans Affairs (VA) primary care who received ≥6 months of opioid analgesics. MEASURES: Self-reported use of each of 10 CIH/nondrug therapies to treat or cope with chronic pain in the past year: meditation/mindfulness, relaxation, psychotherapy, yoga, t'ai chi, aerobic exercise, stretching/strengthening, acupuncture, chiropractic, massage; Brief Pain Inventory-Interference (BPI-I) scale as a measure of pain-related function. RESULTS: In total, 8891 (65%) of 13,660 invitees completed the questionnaire. Eighty percent of veterans reported past-year use of at least 1 nondrug therapy for pain. Younger age and female sex were associated with the use of most nondrug therapies. Higher pain interference was associated with lower use of exercise/movement therapies. Nondrug therapy use patterns reflected functional categories (psychological/behavioral, exercise/movement, manual). CONCLUSIONS: Use of CIH/nondrug therapies for pain was common among patients receiving long-term opioids. Future analyses will examine nondrug therapy use in relation to pain and quality of life outcomes over time.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Crônica/terapia , Terapias Complementares/estatística & dados numéricos , Medicina Integrativa/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Terapias Complementares/métodos , Feminino , Nível de Saúde , Humanos , Medicina Integrativa/métodos , Masculino , Pessoa de Meia-Idade , Manejo da Dor , Percepção da Dor , Qualidade de Vida , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos , United States Department of Veterans Affairs , Saúde dos Veteranos
11.
PLoS One ; 15(8): e0237560, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32857765

RESUMO

Pakistan is considered by the World Health Organization to currently have a "concentrated" HIV-1 epidemic due to a rapid rise in infections among people who inject drugs (PWID). Prevalence among the country's nearly 105,000 PWID is estimated to be 37.8% but has been shown to be higher in several large urban centers. A lack of public health resources, the common use of professional injectors and unsafe injection practices are believed to have fueled the outbreak. Here we evaluate the molecular characteristics of HIV-1 sequences (n = 290) from PWID in several Pakistani cities to examine transmission dynamics and the association between rates of HIV-1 transmission with regards to regional trends in opioid trafficking. Tip-to-tip (patristic) distance based phylogenetic cluster inferences and BEAST2 Bayesian phylodynamic analyses of time-stamped data were performed on HIV-1 pol sequences generated from dried blood spots collected from 1,453 PWID as part of a cross-sectional survey conducted in Pakistan during 2014/2015. Overall, subtype A1 strains were dominant (75.2%) followed by CRF02_AG (14.1%), recombinants/unassigned (7.2%), CRF35_AD (2.1%), G (1.0%) and C (0.3%). Nearly three quarters of the PWID HIV-1 sequences belonged to one of five distinct phylogenetic clusters. Just below half (44.4%) of individuals in the largest cluster (n = 118) did seek help injecting from professional injectors which was previously identified as a strong correlate of HIV-1 infection. Spikes in estimated HIV-1 effective population sizes coincided with increases in opium poppy cultivation in Afghanistan, Pakistan's western neighbor. Structured coalescent analysis was undertaken in order to investigate the spatial relationship of HIV-1 transmission among the various cities under study. In general terms, our analysis placed the city of Larkana at the center of the PWID HIV-1 epidemic in Pakistan which is consistent with previous epidemiological data.


Assuntos
Analgésicos Opioides/administração & dosagem , Infecções por HIV/epidemiologia , Infecções por HIV/transmissão , HIV-1/isolamento & purificação , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Filogenia , Abuso de Substâncias por Via Intravenosa/epidemiologia , Adulto , Estudos Transversais , Feminino , Infecções por HIV/virologia , Soropositividade para HIV , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/virologia , Paquistão/epidemiologia , Adulto Jovem
12.
Yakugaku Zasshi ; 140(8): 1081-1085, 2020.
Artigo em Japonês | MEDLINE | ID: mdl-32741866

RESUMO

Cancer patients often suffer from severe pain related to bone metastasis. We encountered a patient in whom the addition of topical non-steroidal anti-inflammatory drugs (NSAIDs) for persistent pain related to bone metastasis during therapy with opioids and oral NSAIDs reduced pain, improving activities of daily living (ADL). Fentanyl patches, celecoxib, denosumab, and topical NSAIDs (loxoprofen tape, felbinac) were administered to a 72-year-old patient with gastric cancer and pain related to bone metastasis. Pain control was favorable, with a numerical rating scale (NRS) score of 2 and Japanese version Support Team Assessment Schedule (STAS-J) score of 1. Intervention by pharmacists for the use of topical NSAIDs decreased both the NRS and STAS-J scores to zero, improving ADL. The results suggest that topical NSAIDs relieve bone-metastasis-related pain, improving ADL. When bone-metastasis-related pain is localized, the prescription of topical NSAIDs should be considered, and positive intervention by pharmacists regarding their usage should be promoted.


Assuntos
Administração Tópica , Analgésicos Opioides/administração & dosagem , Anti-Inflamatórios não Esteroides/administração & dosagem , Neoplasias Ósseas/secundário , Dor do Câncer/tratamento farmacológico , Dor do Câncer/etiologia , Neoplasias Gástricas/patologia , Atividades Cotidianas , Administração Oral , Idoso , Neoplasias Ósseas/complicações , Neoplasias Ósseas/fisiopatologia , Quimioterapia Combinada , Humanos , Masculino , Resultado do Tratamento
14.
Medicine (Baltimore) ; 99(31): e21435, 2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32756154

RESUMO

INTRODUCTION: The population of obese individuals is increasing worldwide, and as a result, the number of mothers with super morbid obesity undergoing cesarean sections is also increasing. However, little is known about which anesthetic technique is appropriate for cesarean sections of super morbidly obese parturients. PATIENT CONCERNS: A 35-year-old woman with body mass index 61.3 kg/m at a gestational age of 37 weeks. DIAGNOSIS: The patient was super morbidly obese parturient. INTERVENTIONS: Spinal anesthesia was performed. A spinal needle was inserted into the L4-5 interspinous space in the sitting position. After confirmation of cerebrospinal fluid, 0.5% hyperbaric bupivacaine 9 mg and fentanyl 20 µg were injected into the subarachnoid space. OUTCOMES: After the administration of spinal anesthetics, the nerve block to the T8 dermatome level was confirmed, surgery was performed, and the fetus was delivered. The patient's vital signs were stable until the end of the operation. CONCLUSION: There is no established strategy for selecting a method of anesthesia in patients with morbid obesity (body mass index 40 kg/m or more). For this reason and considering the amount of bupivacaine used for spinal anesthesia, we wanted to share our experience with spinal anesthesia for cesarean section in a super morbidly obese parturients.


Assuntos
Anestesia Obstétrica/métodos , Raquianestesia/instrumentação , Cesárea/métodos , Obesidade Mórbida/cirurgia , Adulto , Analgésicos Opioides/administração & dosagem , Anestesia Epidural/métodos , Anestesia Obstétrica/tendências , Raquianestesia/métodos , Anestésicos Locais/administração & dosagem , Índice de Massa Corporal , Bupivacaína/administração & dosagem , Feminino , Fentanila/administração & dosagem , Idade Gestacional , Humanos , Injeções Espinhais , Agulhas , Obesidade Mórbida/epidemiologia , Alta do Paciente/normas , Gravidez
15.
Life Sci ; 257: 118048, 2020 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-32622946

RESUMO

AIMS: Naldemedine is a peripherally acting µ-opioid receptor antagonists (PAMORAs) indicated for the treatment of opioid-induced constipation (OIC). We investigated the preventive effect of naldemedine on morphine-induced nausea and vomiting in ferrets and conducted a pharmacokinetic/pharmacodynamic (PK/PD) analysis. MAIN METHODS: The antiemetic effect of naldemedine was evaluated as the frequency and time of retching (rhythmic abdominal contractile motion) and vomiting (throwing up vomit or similar reactions) caused by morphine in ferrets. After a single oral administration of naldemedine to ferrets, the plasma concentrations of naldemedine and morphine were measured by liquid chromatography-tandem mass spectrometry. KEY FINDINGS: Naldemedine showed a potent and dose-dependent anti-emetic effects against morphine-induced emetic responses, for up to 6 h. The dose of naldemedine that produced half the maximal effect (ED50) value for anti-emetic effect of naldemedine in the morphine-treated ferrets was 0.033 mg/kg. The PK/PD analysis revealed that the antiemetic effect was related to the plasma naldemedine concentration, with a half maximal effective concentration that produces half the maximal effect (EC50) of 3.51 ng/mL. The plasma concentration producing an antiemetic effect was almost 200-fold lower than that inducing an anti-analgesic effect in rats. SIGNIFICANCE: Naldemedine showed potent inhibition of morphine-induced vomiting for up to 6 h after dosing. These data suggest that naldemedine possesses antiemetic properties and could be effective against opioid-induced nausea and vomiting (OINV).


Assuntos
Naltrexona/análogos & derivados , Náusea/tratamento farmacológico , Analgésicos Opioides/administração & dosagem , Animais , Constipação Intestinal/induzido quimicamente , Furões , Masculino , Morfina/efeitos adversos , Naltrexona/metabolismo , Naltrexona/farmacologia , Antagonistas de Entorpecentes/farmacologia , Receptores Opioides mu/antagonistas & inibidores , Vômito/induzido quimicamente
16.
Proc Natl Acad Sci U S A ; 117(32): 19556-19565, 2020 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-32694207

RESUMO

Opioid addiction is a chronic, relapsing disorder associated with persistent changes in brain plasticity. Reconfiguration of neuronal connectivity may explain heightened abuse liability in individuals with a history of chronic drug exposure. To characterize network-level changes in neuronal activity induced by chronic opiate exposure, we compared FOS expression in mice that are morphine-naïve, morphine-dependent, or have undergone 4 wk of withdrawal from chronic morphine exposure, relative to saline-exposed controls. Pairwise interregional correlations in FOS expression data were used to construct network models that reveal a persistent reduction in connectivity strength following opiate dependence. Further, we demonstrate that basal gene expression patterns are predictive of changes in FOS correlation networks in the morphine-dependent state. Finally, we determine that regions of the hippocampus, striatum, and midbrain are most influential in driving transitions between opiate-naïve and opiate-dependent brain states using a control theoretic approach. This study provides a framework for predicting the influence of specific therapeutic interventions on the state of the opiate-dependent brain.


Assuntos
Encéfalo/fisiopatologia , Dependência de Morfina/fisiopatologia , Rede Nervosa/fisiopatologia , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Animais , Encéfalo/efeitos dos fármacos , Encéfalo/metabolismo , Conectoma , Perfilação da Expressão Gênica , Regulação da Expressão Gênica , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Modelos Neurológicos , Morfina/administração & dosagem , Morfina/efeitos adversos , Dependência de Morfina/metabolismo , Rede Nervosa/efeitos dos fármacos , Rede Nervosa/metabolismo , Plasticidade Neuronal/genética , Proteínas Proto-Oncogênicas c-fos/genética , Proteínas Proto-Oncogênicas c-fos/metabolismo , Síndrome de Abstinência a Substâncias/genética , Síndrome de Abstinência a Substâncias/metabolismo , Síndrome de Abstinência a Substâncias/fisiopatologia
17.
Br J Anaesth ; 125(3): 358-372, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32660719

RESUMO

BACKGROUND: Intrathecal hydrophilic opioids decrease systemic opioid consumption after abdominal surgery and potentially facilitate enhanced recovery. A meta-analysis is needed to quantify associated risks and benefits. METHODS: A systematic search was performed to find RCTs investigating intrathecal hydrophilic opioids in abdominal surgery. Caesarean section and continuous regional or neuraxial techniques were excluded. Several subgroup analyses were prespecified. A conventional meta-analysis, meta-regression, trial sequential analysis, and provision of GRADE scores were planned. RESULTS: The search yielded 40 trials consisting of 2500 patients. A difference was detected in 'i.v. morphine consumption' at Day 1 {mean difference [MD] -18.4 mg, (95% confidence interval [CI]: -22.3 to -14.4)} and Day 2 (MD -25.5 mg [95% CI: -30.2 to -20.8]), pain scores at Day 1 in rest (MD -0.9 [95% CI: -1.1 to -0.7]) and during movement (MD -1.2 [95% CI: -1.6 to -0.8]), length of stay (MD -0.2 days [95% CI: -0.4 to -0.1]) and pruritus (relative risk 4.3 [95% CI: 2.5-7.5]) but not in nausea or sedation. A difference was detected for respiratory depression (odds ratio 5.5 [95% CI: 2.1-14.2]) but not when two small outlying studies were excluded (odds ratio 1.4 [95% CI: 0.4-5.2]). The level of evidence was graded as high for morphine consumption, in part because the required information size was reached. CONCLUSIONS: This study showed important opioid-sparing effects of intrathecal hydrophilic opioids. Our data suggest a dose-dependent relationship between the risk of respiratory depression and the dose of intrathecal opioids. Excluding two high-dose studies, intrathecal opioids have a comparable incidence of respiratory depression as the control group. CLINICAL TRIAL REGISTRATION: PROSPERO-registry: CRD42018090682.


Assuntos
Abdome/cirurgia , Analgesia Epidural/métodos , Analgésicos Opioides/uso terapêutico , Analgésicos Opioides/administração & dosagem , Relação Dose-Resposta a Droga , Feminino , Humanos , Gravidez , Insuficiência Respiratória/induzido quimicamente
18.
Am J Gastroenterol ; 115(7): 1125-1128, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32618664

RESUMO

INTRODUCTION: Normal response to multiple rapid swallows (MRS) during high-resolution esophageal manometry is deglutitive inhibition; opioids may interfere with this. The aim of this study was to evaluate the response to MRS in patients on opioids, not on opioids, and healthy controls. METHODS: Response to MRS was evaluated for complete vs impaired inhibition in 72 chronic opioid users, 100 patients not on opioids, and 24 healthy controls. RESULTS: Impaired deglutitive inhibition was significantly more frequent in chronic opioid users compared with patients not on opioids and healthy controls (54% vs 14% vs 0%; P < 0.0001). DISCUSSION: Impaired deglutitive inhibition during MRS is frequent in opioid users, supporting that opioids interfere with esophageal inhibitory signals.


Assuntos
Analgésicos Opioides/administração & dosagem , Deglutição/efeitos dos fármacos , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Manometria , Pessoa de Meia-Idade
19.
Ann Surg ; 272(2): 304-310, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32675543

RESUMO

OBJECTIVE: To describe if patients with chronic opioid use with a consistent usual prescriber (UP) prior to surgery and if early return to that UP (<30 d) would be associated with fewer high risk prescribing events in the postoperative period. SUMMARY BACKGROUND DATA: Over 10 million people each year are prescribed opioids for chronic pain. There is little evidence regarding coordination of opioid management and best practices for patients on long-term opioid therapy patients following surgery. METHODS: The study design is a retrospective cohort study. We identified 5749 commercially insured patients aged 18 to 64 with chronic opioid use who underwent elective surgery between January 2008 and March 2015. The predictors were presence of a UP and early return (<30 d from surgery) to a UP. The primary outcome was new high-risk opioid prescribing in the 90-day postoperative period (multiple prescribers, overlapping opioid and/or benzodiazepine prescriptions, new long acting opioid prescriptions, or new dose escalations to > 100 mg OME). RESULTS: In this cohort, 73.8% of patients were exposed to high risk prescribing postoperatively. Overall, 10% of patients did not have a UP preoperatively, and were more likely to have prescriptions from multiple prescribers (OR 2.23 95% CI 1.75-2.83) and new long acting opioid prescriptions (OR 1.69, 95% CI 1.05-2.71). Among patients with a UP, earlier return was associated with decreased odds of receiving prescriptions from multiple prescribers (OR 0.80, 95% CI 0.68-0.95). CONCLUSION: Patients without a UP prior to surgery are more likely to be exposed to high-risk opioid prescribing following surgery. Among patients who have a UP, early return visits may enhance care coordination with fewer prescribers.


Assuntos
Analgésicos Opioides/administração & dosagem , Uso de Medicamentos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Uso Indevido de Medicamentos sob Prescrição/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Analgésicos Opioides/efeitos adversos , Dor Crônica/tratamento farmacológico , Estudos de Coortes , Feminino , Seguimentos , Humanos , Incidência , Modelos Logísticos , Masculino , Michigan , Pessoa de Meia-Idade , Análise Multivariada , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Manejo da Dor/métodos , Dor Pós-Operatória/diagnóstico , Equipe de Assistência ao Paciente/organização & administração , Padrões de Prática Médica , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos , Adulto Jovem
20.
PLoS One ; 15(7): e0236243, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32722721

RESUMO

BACKGROUND: Cannabis is one of the most widely used substances among vulnerable young people (<26 years of age) experiencing street entrenchment. Although previous research has documented the role cannabis can play in harm reduction, substance use and mental health treatment and pain management, this research has predominantly been quantitative and focused on adult drug-using populations. Little qualitative work has examined how young people who use drugs understand, experience, and engage with cannabis in the context of street entrenchment and drug use trajectories that include the use of other substances such as alcohol, opioids and crystal methamphetamine (meth). METHODS: Semi-structured, in-depth qualitative interviews were conducted between 2017 and 2019 with 56 young people recruited from a cohort of street-involved youth in Vancouver, Canada. We also conducted 13 interviews with 12 youth-focused care providers across the same time period. Interview data were triangulated by drawing on the findings of a program of anthropological research conducted by the senior author since 2008. Interviews were transcribed verbatim and thematic analysis was conducted. RESULTS: The vast majority of study participants engaged in daily, intensive cannabis use at the same time as they cycled on and off other substances that were perceived as much more harmful (primarily alcohol, fentanyl, heroin and meth). While most participants derived significant pleasure from the use of cannabis, no participants in our study described using cannabis for purely recreational purposes. A number of participants explicitly framed cannabis as a form of mental health and substance use treatment that was more effective and "healthier" than the long-term use of psychopharmaceuticals and medication-assisted substance use treatment (e.g., opioid agonist therapies). Cannabis use was also understood to ameliorate some of the harms of, or even facilitate transitions out of, periods of street-based homelessness. While the majority of our participants highlighted the positive effects of regular cannabis consumption, some described how intensive cannabis use could generate significant harms. CONCLUSION: In the context of the recent legalization of non-medical cannabis use in Canada and amid ongoing overdose and housing crises, it is imperative that future policy and programming interventions and provider education and training be responsive to the ways in which vulnerable youth in our setting are actively using cannabis to navigate their everyday lives and healthcare needs.


Assuntos
Usuários de Drogas/psicologia , Adolescente , Analgésicos Opioides/administração & dosagem , Feminino , Redução do Dano , Pessoas em Situação de Rua/psicologia , Humanos , Entrevistas como Assunto , Masculino , Saúde Mental , Transtornos Relacionados ao Uso de Substâncias/etiologia , Adulto Jovem
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