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1.
Cochrane Database Syst Rev ; 12: CD013217, 2020 12 21.
Artigo em Inglês | MEDLINE | ID: mdl-33348423

RESUMO

BACKGROUND: The prevalence of substance use, both prescribed and non-prescribed, is increasing in many areas of the world. Substance use by women of childbearing age contributes to increasing rates of neonatal abstinence syndrome (NAS). Neonatal opioid withdrawal syndrome (NOWS) is a newer term describing the subset of NAS related to opioid exposure. Non-pharmacological care is the first-line treatment for substance withdrawal in newborns. Despite the widespread use of non-pharmacological care to mitigate symptoms of NAS, there is not an established definition of, and standard for, non-pharmacological care practices in this population. Evaluation of safety and efficacy of non-pharmacological practices could provide clear guidance for clinical practice. OBJECTIVES: To evaluate the safety and efficacy of non-pharmacological treatment of infants at risk for, or having symptoms consistent with, opioid withdrawal on the length of hospitalization and use of pharmacological treatment for symptom management. Comparison 1: in infants at risk for, or having early symptoms consistent with, opioid withdrawal, does non-pharmacological treatment reduce the length of hospitalization and use of pharmacological treatment? Comparison 2: in infants receiving pharmacological treatment for symptoms consistent with opioid withdrawal, does concurrent non-pharmacological treatment reduce duration of pharmacological treatment, maximum and cumulative doses of opioid medication, and length of hospitalization? SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 10); Ovid MEDLINE; and CINAHL on 11 October 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster trials. SELECTION CRITERIA: We included trials comparing single or bundled non-pharmacological interventions to no non-pharmacological treatment or different single or bundled non-pharmacological interventions. We assessed non-pharmacological interventions independently and in combination based on sufficient similarity in population, intervention, and comparison groups studied. We categorized non-pharmacological interventions as: modifying environmental stimulation, feeding practices, and support of the mother-infant dyad. We presented non-randomized studies identified in the search process narratively. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Primary outcomes in infants at risk for, or having early symptoms consistent with, opioid withdrawal included length of hospitalization and pharmacological treatment with one or more doses of opioid or sedative medication. Primary outcomes in infants receiving opioid treatment for symptoms consistent with opioid withdrawal included length of hospitalization, length of pharmacological treatment with opioid or sedative medication, and maximum and cumulative doses of opioid medication. MAIN RESULTS: We identified six RCTs (353 infants) in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated between 1975 and 2018. We identified no RCTs in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. The certainty of evidence for all outcomes was very low to low. We also identified and excluded 34 non-randomized studies published between 2005 and 2018, including 29 in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated and five in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. We identified seven preregistered interventional clinical trials that may qualify for inclusion at review update when complete. Of the six RCTs, four studies assessed modifying environmental stimulation in the form of a mechanical rocking bed, prone positioning, non-oscillating waterbed, or a low-stimulation nursery; one study assessed feeding practices (comparing 24 kcal/oz to 20 kcal/oz formula); and one study assessed support of the maternal-infant dyad (tailored breastfeeding support). There was no evidence of a difference in length of hospitalization in the one study that assessed modifying environmental stimulation (mean difference [MD) -1 day, 95% confidence interval [CI) -2.82 to 0.82; 30 infants; very low-certainty evidence) and the one study of support of the maternal-infant dyad (MD -8.9 days, 95% CI -19.84 to 2.04; 14 infants; very low-certainty evidence). No studies of feeding practices evaluated the length of hospitalization. There was no evidence of a difference in use of pharmacological treatment in three studies of modifying environmental stimulation (typical risk ratio [RR) 1.00, 95% CI 0.86 to 1.16; 92 infants; low-certainty evidence), one study of feeding practices (RR 0.92, 95% CI 0.63 to 1.33; 49 infants; very low-certainty evidence), and one study of support of the maternal-infant dyad (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). Reported secondary outcomes included neonatal intensive care unit (NICU) admission, days to regain birth weight, and weight nadir. One study of support of the maternal-infant dyad reported NICU admission (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). One study of feeding practices reported days to regain birth weight (MD 1.10 days, 95% CI 2.76 to 0.56; 46 infants; very low-certainty evidence). One study that assessed modifying environmental stimulation reported weight nadir (MD -0.28, 95% CI -1.15 to 0.59; 194 infants; very low-certainty evidence) and one study of feeding practices reported weight nadir (MD -0.8, 95% CI -2.24 to 0.64; 46 infants; very low-certainty evidence). AUTHORS' CONCLUSIONS: We are uncertain whether non-pharmacological care for opioid withdrawal in newborns affects important clinical outcomes including length of hospitalization and use of pharmacological treatment based on the six included studies. The outcomes identified for this review were of very low- to low-certainty evidence. Combined analysis was limited by heterogeneity in study design and intervention definitions as well as the number of studies. Many prespecified outcomes were not reported. Although caregivers are encouraged by experts to optimize non-pharmacological care for opioid withdrawal in newborns prior to initiating pharmacological care, we do not have sufficient evidence to inform specific clinical practices. Larger well-designed studies are needed to determine the effect of non-pharmacological care for opioid withdrawal in newborns.


Assuntos
Tempo de Internação , Entorpecentes/efeitos adversos , Síndrome de Abstinência Neonatal/terapia , Leitos , Aleitamento Materno , Planejamento Ambiental , Humanos , Hipnóticos e Sedativos/uso terapêutico , Equipamentos para Lactente , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Síndrome de Abstinência Neonatal/tratamento farmacológico , Berçários para Lactentes , Tratamento de Substituição de Opiáceos/métodos , Posicionamento do Paciente/métodos , Decúbito Ventral , Ensaios Clínicos Controlados Aleatórios como Assunto
2.
Medicine (Baltimore) ; 99(36): e22070, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32899074

RESUMO

BACKGROUND: A number of recent studies have investigated the optimal dosage and timing of dexamethasone in total hip arthroplasty (THA) but have inconsistent findings. Therefore, we designed the randomized controlled research to look for the optimal intravenous dexamethasone dose for the treatment of early postoperative pain after the THA. METHODS: The Declaration of Helsinki principles was followed and the Consolidated Standards of Reporting Trials guidelines for randomized controlled trials was adhered in this study. The First Medical Center in People's Liberation Army General Hospital approved the study (2020-089). After written informed consent was obtained, patients aged between 18 and 80 years with Physical Status I to III of American Society of Anesthesiologists, scheduled for primary unilateral THA, were included in this present work. Randomization is the use of a computer-formed list via a secretary, at a ratio of 1:1:1. The major end points were pain scores at 24 hours, 48 hours, and 72 hours after surgery, with visual analog scale (VAS) utilized at rest, and at 45 degrees passive hip flexion. The secondary outcomes involved the total consumption of morphine, opioid-related side effects, hip range of motion, inflammation markers, and the length of hospital stay. RESULTS: We assumed that the patients who received 3 doses of dexamethasone intravenously possessed the best postoperative results compared to those who received 1 or 2 doses of the dexamethasone. TRIAL REGISTRATION: This study protocol was registered in Research Registry (researchregistry5864).


Assuntos
Anti-Inflamatórios/administração & dosagem , Artroplastia de Quadril/efeitos adversos , Dexametasona/administração & dosagem , Dor Pós-Operatória/tratamento farmacológico , Administração Intravenosa , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Inflamatórios/uso terapêutico , Estudos de Casos e Controles , Dexametasona/uso terapêutico , Humanos , Mediadores da Inflamação/metabolismo , Tempo de Internação , Pessoa de Meia-Idade , Morfina/efeitos adversos , Entorpecentes/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Amplitude de Movimento Articular , Escala Visual Analógica , Adulto Jovem
3.
Ann Hematol ; 99(10): 2429-2436, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32839869

RESUMO

Patients receiving vinca alkaloids for hematological malignancies frequently experience constipation that is unresponsive to laxatives. Research on treatment of vinca alkaloid-induced constipation is limited. This study aimed to determine whether the chloride channel activator lubiprostone ameliorates vinca alkaloid-induced constipation in patients with hematological malignancies. In this retrospective cohort study, vinca alkaloid-induced constipation (grade ≥ 3 using the Common Terminology Criteria for Adverse Events) was investigated in patients treated for hematological malignancies between July 2014 and June 2019 who had already been prescribed osmotic laxatives and additionally received either a stimulant laxative or lubiprostone. Univariate and multivariate analyses were performed to identify the risk factors for persistent constipation after introduction of the second laxative. A propensity score model was used to match 67 patients taking a stimulant laxative and 67 treated with lubiprostone, and the occurrence of intractable constipation was compared between groups. Overall, 203 patients were included, among whom 50 (25%) had constipation. On multivariate analysis, body mass index, opioid use, and addition of lubiprostone were independently associated with constipation. Patients treated with lubiprostone were significantly less likely to experience intractable constipation than did those treated with stimulant laxatives (10% vs. 34%, P = 0.002). Moreover, post-constipation diarrhea was significantly less frequent among patients treated with lubiprostone (42% vs. 63%, P = 0.024). Lubiprostone was more effective than stimulant laxatives at treating vinca alkaloid-induced intractable constipation in patients with hematological malignancies, and its use could enable safe vinca alkaloid chemotherapy.


Assuntos
Antineoplásicos Fitogênicos/efeitos adversos , Agonistas dos Canais de Cloreto/uso terapêutico , Constipação Intestinal/tratamento farmacológico , Neoplasias Hematológicas/tratamento farmacológico , Lubiprostona/uso terapêutico , Linfoma/tratamento farmacológico , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamento farmacológico , Alcaloides de Vinca/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos Fitogênicos/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Constipação Intestinal/induzido quimicamente , Ciclofosfamida/administração & dosagem , Doxorrubicina/administração & dosagem , Avaliação de Medicamentos , Quimioterapia Combinada , Famotidina/uso terapêutico , Feminino , Humanos , Laxantes/farmacologia , Laxantes/uso terapêutico , Óxido de Magnésio/uso terapêutico , Masculino , Pessoa de Meia-Idade , Entorpecentes/efeitos adversos , Prednisona/administração & dosagem , Pontuação de Propensão , Inibidores da Bomba de Prótons/uso terapêutico , Estudos Retrospectivos , Fatores de Risco , Senosídeos/uso terapêutico , Alcaloides de Vinca/administração & dosagem , Vincristina/administração & dosagem
4.
Zhonghua Liu Xing Bing Xue Za Zhi ; 41(4): 615-620, 2020 Apr 10.
Artigo em Chinês | MEDLINE | ID: mdl-32344492

RESUMO

Both narcotic and psychotropic drugs are more often used to alleviate related multiple physical or mental health problems, but these drugs are very easily addicted to. With the aging of population, abuse of narcotic drugs and psychotropic drugs among the elderly are called for more attention. In this paper, harms caused by the abuse of anesthetic and psychotropic drugs, current situation and causes related to the abuse of anesthetic and psychotropic drugs as well as risk factors and preventive measures regarding the abuse of anesthetic and psychotropic drugs, among the elderly, are reviewed.


Assuntos
Entorpecentes/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Psicotrópicos/efeitos adversos , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Psicotrópicos/uso terapêutico , Transtornos Relacionados ao Uso de Substâncias/epidemiologia
6.
Ann Palliat Med ; 9(2): 611-624, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32156127

RESUMO

Fentanyl has been FDA approval as an analgesic since 1968 and multiple different fentanyl preparations have been developed over the years. Little was known about it is clinical utility defined by risks and benefits until recently. Present commercially available preparations are easily tampered and nonpharmacologic fentanyl has become the major cause of opioid deaths in the United States. This state-ofthe-art review will discuss fentanyl pharmacology, utility, safety and abuse.


Assuntos
Analgésicos Opioides/efeitos adversos , Fentanila/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor/tratamento farmacológico , Analgésicos Opioides/uso terapêutico , Fentanila/uso terapêutico , Humanos , Entorpecentes/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/etiologia , Saúde Pública , Estados Unidos
7.
Rev. Hosp. Ital. B. Aires (2004) ; 40(1): 34-38, mar. 2020. tab
Artigo em Espanhol | LILACS | ID: biblio-1102292

RESUMO

Las mujeres han sido tratadas por décadas con testosterona intentando aliviar una gran variedad de síntomas con riesgos y beneficios inciertos. En la mayoría de los países, la testosterona se prescribe "off-label", de modo que las mujeres están utilizando compuestos y dosis ideadas para tratamientos en hombres. En este sentido, varias sociedades médicas de distintos continentes adoptaron recientemente por consenso una toma de posición sobre los beneficios y potenciales riesgos de la terapia con testosterona en la mujer, explorar las áreas de incertidumbre e identificar prácticas de prescripción con potencial de causar daño. Las recomendaciones con respecto a los beneficios y riesgos de la terapia con testosterona se basan en los resultados de ensayos clínicos controlados con placebo de al menos 12 semanas de duración. A continuación se comentan las recomendaciones. (AU)


There are currently no clear established indications for testosterone replacement therapy for women. Nonetheless, clinicians have been treating women with testosterone to alleviate a variety of symptoms for decades with uncertainty regarding its benefits and risks. In most countries, testosterone therapy is prescribed off-label, which means that women are using testosterone formulations or compounds approved for men with a modified dose for women. Due to these issues, there was a need for a global Consensus Position Statement on testosterone therapy for women based on the available evidence from placebo randomized controlled trials (RCTs). This Position Statement was developed to inform health care professionals about the benefits and potential risks of testosterone therapy intended for women. The aim of the Consensus was to provide clear guidance as to which women might benefit from testosterone therapy; to identify symptoms, signs, and certain conditions for which the evidence does not support the prescription of testosterone; to explore areas of uncertainty, and to identify any prescribing practices that have the potential to cause harm. (AU)


Assuntos
Humanos , Feminino , Idoso , Testosterona/uso terapêutico , Pós-Menopausa/efeitos dos fármacos , Depressores do Apetite/efeitos adversos , Fenitoína/efeitos adversos , Placebos/administração & dosagem , Psicotrópicos/efeitos adversos , Tamoxifeno/efeitos adversos , Testosterona/administração & dosagem , Testosterona/análise , Testosterona/efeitos adversos , Testosterona/farmacologia , Fármacos Cardiovasculares/efeitos adversos , Indometacina/efeitos adversos , Hormônio Liberador de Gonadotropina/efeitos adversos , Pós-Menopausa/fisiologia , Ensaios Clínicos Controlados como Assunto , Antagonistas Colinérgicos/efeitos adversos , Anticoncepcionais Orais/efeitos adversos , Disfunções Sexuais Psicogênicas/etiologia , Disfunções Sexuais Psicogênicas/terapia , Danazol/efeitos adversos , Consenso , Inibidores da Aromatase/efeitos adversos , Uso Off-Label , Inibidores do Fator Xa/efeitos adversos , Anfetaminas/efeitos adversos , Antagonistas dos Receptores Histamínicos/efeitos adversos , Antagonistas de Androgênios/efeitos adversos , Androgênios/fisiologia , Cetoconazol/efeitos adversos , Entorpecentes/efeitos adversos
8.
Semin Thorac Cardiovasc Surg ; 32(3): 404-412, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31972300

RESUMO

To improve surgical pain control through cryoablation of intercostal nerves and reduce narcotic usage in patients undergoing open thoracic or thoracoabdominal aortic aneurysm (TAA or TAAA) repair. From 2012 to 2018, 117 patients underwent open repair of TAA or TAAA. Of those patients, 25 (21%) received cryoablation (2016-2018) of their intercostal nerves and 92 (79%) did not (2012-2018). The primary outcome was pain scores and narcotic usage from extubation day 1 to 10 or the day of discharge. The median age (57 years), demographics, and preoperative comorbidities were not significantly different between the 2 groups. The cryoablation group had significantly more incidences of thoracoabdominal incisions (52% vs 28%), urgent operations (32% vs 11%), and longer duration of chest tubes compared to the noncryoablation group (all P < 0.05). T9-T12 intercostal arteries were selectively reimplanted. Left intercostal nerves were cryoablated from T3 to T9 if 2 thoracotomies were used; or 2 intercostal spaces above and below the thoracotomy if 1 thoracotomy was used. There were no significant differences between the noncryoablation and cryoablation groups in postoperative stroke, paraplegia (5%), pneumonia, and in-hospital mortality (0.9%). However, the average usage of narcotics was significantly reduced in the cryoablation group by 28 measured morphine equivalents (equal to four 5 mg Oxycodone)/patient/day in 10 days after extubation, P = 0.005. With cryoablation of intercostal nerves, the postoperative surgical pain was well controlled and narcotic usage was significantly decreased after TAA or TAAA repair. Cryoablation of intercostal nerves was a safe and effective measure for postoperative pain control in TAA or TAAA repair.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Criocirurgia , Denervação , Nervos Intercostais/cirurgia , Entorpecentes/administração & dosagem , Manejo da Dor/métodos , Dor Pós-Operatória/prevenção & controle , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Implante de Prótese Vascular/efeitos adversos , Criocirurgia/efeitos adversos , Denervação/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Entorpecentes/efeitos adversos , Manejo da Dor/efeitos adversos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
9.
Ann Vasc Surg ; 66: 301-308, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31857230

RESUMO

BACKGROUND: Postoperative analgesia in patients undergoing transaxillary thoracic outlet decompression (TATOD) is challenging because of the invasive surgery, the complex innervation of the axillary region, and the preoperative use of opioids by many patients. Commonly, postoperative pain is managed with additional opioids that introduce well-known sideeffects. To investigate the analgesic efficacy of 2 novel regional anesthesia techniques, we performed a retrospective study comparing the combined pectoral block type 1 and erector spinae block (PECS 1 + ESB) and the pectoral block type 2 (PECS 2) and systemic intravenous opioids regimen (no block) in patients undergoing TATOD. MATERIALS AND METHODS: We performed 10 PECS 1 + ESB and 10 PECS 2 blocks in patients undergoing TATOD. Twenty patients were randomly selected as controls. The primary endpoint was pain. Secondary endpoints were opioid use, nausea, and vomiting. RESULTS: Postoperative maximal numeric rating scale scores on recovery were significantly lower in patients receiving either a PECS 1 + ESB or a PECS 2 block compared with controls without block (no block: median 6.00, interquartile range [IQR] 3.00; PECS 1 + ESB: median 4.50, IQR 4.00; PECS 2: median 4.00, IQR 5.00; P = 0.031). Postoperative intravenous morphine consumption was 43% lower in the PECS 1 + ESB group and 56% lower in the PECS 2 group compared with the group with no block (oral morphine equivalents; no block: mean 16.05 ± SD 6.79 mg; PECS 1 + ESB mean 9.05 ± SD 6.24 mg; PECS 2: mean 7.00 ± SD 6.16; P = 0.03 and P = 0.003, respectively). There was no statistical difference in both nausea and vomitus (no block 45% nausea and 30% vomitus, PECS 1 + ESB 40% nausea and 20% vomitus, PECS 2 10% nausea and 0% vomitus, P = 0.17 and P = 0.14, respectively). CONCLUSIONS: There was a significant reduction in postoperative pain and opioid consumption for patients treated with either the PECS 1 + ESB block or PECS 2.


Assuntos
Descompressão Cirúrgica/efeitos adversos , Morfina/administração & dosagem , Entorpecentes/administração & dosagem , Bloqueio Nervoso , Manejo da Dor/métodos , Dor Pós-Operatória/prevenção & controle , Síndrome do Desfiladeiro Torácico/cirurgia , Adulto , Uso de Medicamentos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Morfina/efeitos adversos , Entorpecentes/efeitos adversos , Bloqueio Nervoso/efeitos adversos , Manejo da Dor/efeitos adversos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Náusea e Vômito Pós-Operatórios/etiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
10.
Ann Vasc Surg ; 66: 289-300.e2, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31678548

RESUMO

BACKGROUND: The use of IV narcotic analgesics (IVNA) within the context of vascular procedures is not fully described. We sought to evaluate the burden of IVNA including narcotic analgesia-related adverse drug events (NARADE), associated mortality and hospitalization cost in open and endovascular vascular procedures, and to compare it with nonnarcotic analgesia (IVNNA). METHODS: Retrospective cross-sectional study in hospitals participating in Premier database (2009-2015). Logistic regression analysis was implemented to report the risks of NARADE and in-hospital mortality. Negative binomial regression was used to assess length of stay and generalized linear modeling was used to estimate the hospitalization cost. RESULTS: A total of 171,473 patients were identified. NARADE occurred in 6.2% of the cohort. NARADE group was similar in gender and race but was slightly older (median age 71 vs. 70; P < 0.001). After risk-adjustment, NARADE risk was higher in patients who received IVNA-alone in carotid and lower extremity revascularization (LER) [OR (odds ratio) (95% confidence interval [CI]): 1.17 (1.02-1.34) and 1.31 (1.14-1.50)] or combined with IVNNA [OR (95% CI): 1.34 (1.13-1.59) and 1.81 (1.54-2.13)], respectively. Patients receiving aortic repair benefited from the use of IVNA + IVNNA [OR (95% CI): 0.82 (0.69-0.98)]. Occurrence of NARADE doubled the LOS, amplified mortality risk and increased cost in all domains. NARADE increased the odds of mortality by 24.3, 6.5 (4.9-8.68) and 16.6 times and added $5,368, $12,737 and $11,349 to the cost of carotid, aortic and LER interventions, respectively. In contrast, IVNNA was not associated with NARADE risk, increased LOS or cost and showed a survival benefit in patients undergoing open aortic repair [aOR (95% CI): 0.52 (0.36-0.75)]. CONCLUSIONS AND RELEVANCE: The use of opioid-based narcotics had increased the risk of NARADE, resources utilization and NARADE-related mortality. Yet the use of nonopioid-based analgesic was safe, did not increase the cost and reduced mortality in open AA repair. This entices shifting the paradigm toward exploring nonopioid-based analgesia options in order to replace or minimize opioid requirements.


Assuntos
Analgésicos não Entorpecentes/administração & dosagem , Analgésicos não Entorpecentes/economia , Custos de Medicamentos , Procedimentos Endovasculares/economia , Custos Hospitalares , Entorpecentes/administração & dosagem , Entorpecentes/economia , Manejo da Dor/economia , Procedimentos Cirúrgicos Vasculares/economia , Administração Intravenosa , Idoso , Analgésicos não Entorpecentes/efeitos adversos , Análise Custo-Benefício , Estudos Transversais , Bases de Dados Factuais , Custos de Medicamentos/tendências , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Procedimentos Endovasculares/tendências , Feminino , Custos Hospitalares/tendências , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Entorpecentes/efeitos adversos , Manejo da Dor/efeitos adversos , Manejo da Dor/mortalidade , Manejo da Dor/tendências , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade , Procedimentos Cirúrgicos Vasculares/tendências
11.
PLoS One ; 14(11): e0225376, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31751394

RESUMO

BACKGROUND: The United States is experiencing a continuing crisis of gun violence, and economically marginalized and racially segregated inner-city areas are among the most affected. To decrease this violence, public health interventions must engage with the complex social factors and structural drivers-especially with regard to the clandestine sale of narcotics-that have turned the neighborhood streets of specific vulnerable subgroups into concrete killing fields. Here we present a mixed-methods ethnographic and epidemiological assessment of narcotics-driven firearm violence in Philadelphia's impoverished, majority Puerto Rican neighborhoods. METHODS: Using an exploratory sequential study design, we formulated hypotheses about ethnic/racial vulnerability to violence, based on half a dozen years of intensive participant-observation ethnographic fieldwork. We subsequently tested them statistically, by combining geo-referenced incidents of narcotics- and firearm-related crime from the Philadelphia police department with census information representing race and poverty levels. We explored the racialized relationships between poverty, narcotics, and violence, melding ethnography, graphing, and Poisson regression. FINDINGS: Even controlling for poverty levels, impoverished majority-Puerto Rican areas in Philadelphia are exposed to significantly higher levels of gun violence than majority-white or black neighborhoods. Our mixed methods data suggest that this reflects the unique social position of these neighborhoods as a racial meeting ground in deeply segregated Philadelphia, which has converted them into a retail endpoint for the sale of astronomical levels of narcotics. IMPLICATIONS: We document racial/ethnic and economic disparities in exposure to firearm violence and contextualize them ethnographically in the lived experience of community members. The exceptionally concentrated and high-volume retail narcotics trade, and the violence it generates in Philadelphia's poor Puerto Rican neighborhoods, reflect unique structural vulnerability and cultural factors. For most young people in these areas, the narcotics economy is the most readily accessible form of employment and social mobility. The performance of violence is an implicit part of survival in these lucrative, illegal narcotics markets, as well as in the overcrowded jails and prisons through which entry-level sellers cycle chronically. To address the structural drivers of violence, an inner-city Marshall Plan is needed that should include well-funded formal employment programs, gun control, re-training police officers to curb the routinization of brutality, reform of criminal justice to prioritize rehabilitation over punishment, and decriminalization of narcotics possession and low-level sales.


Assuntos
Armas de Fogo , Entorpecentes/efeitos adversos , Violência , Antropologia Cultural , Cultura , Feminino , Humanos , Masculino , Porto Rico , Meio Social
12.
Innovations (Phila) ; 14(6): 512-518, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31564183

RESUMO

OBJECTIVE: Minimally invasive cardiac surgery via a right minithoracotomy (RMT) is a common approach to different valve pathologies, tumor resection, and atrial septal defect (ASD) closure. We studied intraoperative field block using liposomal bupivacaine (LB) in these operations. METHODS: Consecutive 171 minimally invasive RMTs (fourth intercostal space) were studied, and patients in cardiogenic or septic shock, intravenous drug abuse, and those re-explored were excluded (n = 12). An early cohort was treated with standard postoperative analgesia while another underwent intraoperative field block with LB immediately after incision. We compared postoperative pain level, narcotic utilization (morphine milligram equivalent), and intensive care unit (ICU) and hospital length of stay. RESULTS: The procedures included 48 isolated mitral valve replacements (MVR); 2 MVR with other procedures; 93 mitral valve repairs (MVRr); 9 MVRr with other procedures; 4 isolated tricuspid valve repairs; 2 myxoma resections; 1 ASD closure. There were 13 patients in the non-LB group and 146 patients in the LB group. Use of LB decreased mean postoperative narcotic utilization by 50% (P = 0.003). The LB group had lower pain levels on postoperative day 1 (P = 0.039), which continued through postoperative day 5 (P = 0.030). We found no difference in ICU or hospital length of stay between groups. There were no complications from LB field block. CONCLUSIONS: LB field block decreases postoperative pain and narcotic utilization after cardiac surgery via a RMT, but it does not reduce length of stay. The technique is safe and should be considered in all patients undergoing RMT cardiac surgery.


Assuntos
Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Anestésicos Locais/uso terapêutico , Bupivacaína/uso terapêutico , Procedimentos Cirúrgicos Cardíacos/métodos , Uso de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/tendências , Feminino , Átrios do Coração/cirurgia , Neoplasias Cardíacas/cirurgia , Comunicação Interatrial/cirurgia , Valvas Cardíacas/cirurgia , Humanos , Cuidados Intraoperatórios/métodos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Mixoma/cirurgia , Entorpecentes/efeitos adversos , Entorpecentes/uso terapêutico , Manejo da Dor/métodos , Dor Pós-Operatória/epidemiologia , Estudos Retrospectivos , Toracotomia/métodos
14.
ESC Heart Fail ; 6(6): 1149-1160, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31389157

RESUMO

AIMS: Morphine is shown to relieve chronic breathlessness in chronic obstructive pulmonary disease. There are no definitive data in people with heart failure. We aimed to determine the effectiveness and cost-effectiveness of 12 weeks morphine therapy for the relief of chronic breathlessness in people with chronic heart failure compared with placebo. METHODS AND RESULTS: Parallel group, double-blind, randomized, placebo-controlled, phase III trial of 20 mg daily oral modified release morphine was conducted in 13 sites in England and Scotland: hospital/community cardiology or palliative care outpatients. The primary analysis compared between-group numerical rating scale average breathlessness/24 hours at week 4 using a covariance pattern linear mixed model. Secondary outcomes included treatment-emergent harms (worse or new). The trial closed early due to slow recruitment, randomizing 45 participants [average age 72 (range 39-89) years; 84% men; 98% New York Heart Association class III]. For the primary analysis, the adjusted mean difference was 0.26 (95% confidence interval, -0.86 to 1.37) in favour of placebo. All other breathlessness measures improved in both groups (week 4 change-from-baseline) but by more in those assigned to morphine. Neither group was excessively drowsy at baseline or week 4. There were no between-group differences in quality of life (Kansas) or cognition (Montreal) at any time point. There was no exercise-related desaturation and no change between baseline and week 4 in either group. There was no change in vital signs at week 4. The natriuretic peptide measures fell in both groups but by more in the morphine group [morphine 2169 (1092, 3851) pg/mL vs. placebo 2851 (1694, 5437)] pg/mL. There was no excess serious adverse events in the morphine group. Treatment-emergent harms during the first week were more common in the morphine group; all apart from 1 were ≤ grade 2. CONCLUSIONS: We could not answer our primary objectives due to inadequate power. However, we provide novel placebo-controlled medium-term benefit and safety data useful for clinical practice and future trial design. Morphine should only be prescribed in this population when other measures are unhelpful and with early management of side effects.


Assuntos
Dispneia , Insuficiência Cardíaca/complicações , Morfina , Entorpecentes , Administração Oral , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica/tratamento farmacológico , Método Duplo-Cego , Dispneia/tratamento farmacológico , Dispneia/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Morfina/efeitos adversos , Morfina/uso terapêutico , Entorpecentes/administração & dosagem , Entorpecentes/efeitos adversos , Entorpecentes/uso terapêutico
15.
Clin J Pain ; 35(10): 836-843, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31318725

RESUMO

OBJECTIVE: To investigate the efficacy and safety of combination analgesic products containing low-dose codeine (up to 30 mg/dose) for pain. METHODS: Electronic databases were used to identify eligible placebo-controlled, randomized controlled trials (RCTs). Two authors extracted data and assessed the risk of bias. Data were pooled using a random-effects model with the strength of evidence assessed using Grading of Recommendations Assessment, Development and Evaluation. The primary outcome was immediate pain relief (3 hours post administration) on a 0 to 100 pain scale. RESULTS: Ten RCTs were eligible. There is low-quality evidence (4 RCTs, n=211 participants) that a single dose of a combination analgesic product (with an nonsteroidal anti-inflammatory) containing low-dose codeine (15 to 30 mg) provides small pain relief for acute dental pain (mean difference [MD], -12.7; 95% confidence interval [CI], -18.5 to -6.9) and moderate-quality evidence (1 RCT, n=93) of small pain relief for post-episiotomy pain and orthopedic surgery pain (MD,, -10.0; 95% CI, -19.0 to -1.0 and MD, -11.0; 95% CI, -20.7 to -1.3), respectively. There is low-quality evidence (1 RCT, n=80) that a multiple-dose regimen provides small pain relief for acute pain following photorefractive keratectomy (MD, -16.0; 95% CI, -24.5 to -7.5) and moderate-quality evidence of moderate pain relief for certain chronic pain conditions: for hip osteoarthritis (MD, -19.0; 95% CI, -31.2 to -6.8) and for temporomandibular joint pain (MD, -26.0; 95% CI, -44.5 to -7.5). Two studies reported a higher incidence of drowsiness in the treatment group compared with the placebo group (relative risk, 8.50; 95% CI, 1.96, 36.8 and 19.3; 95% CI, 1.2-306.5, respectively). DISCUSSION: There is low to moderate level evidence that combination analgesic products containing low-dose codeine provide small to moderate pain relief for acute and chronic pain conditions in the immediate short term with limited trial data on use beyond 24 hours. Further research examining regular use of these medicines is needed with more emphasis on measuring potential harmful effects.


Assuntos
Analgésicos/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Codeína/uso terapêutico , Entorpecentes/uso terapêutico , Dor/tratamento farmacológico , Analgésicos/administração & dosagem , Analgésicos/efeitos adversos , Anti-Inflamatórios não Esteroides/administração & dosagem , Anti-Inflamatórios não Esteroides/efeitos adversos , Codeína/administração & dosagem , Codeína/efeitos adversos , Combinação de Medicamentos , Humanos , Entorpecentes/administração & dosagem , Entorpecentes/efeitos adversos
16.
Neurotoxicology ; 75: 9-13, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31326535

RESUMO

BACKGROUND DATA: Little data exists regarding the effect of chronic preoperative tramadol abuse on the clinical outcomes after surgery. Lumbar discectomy is a very common procedure that has a predictably high success rate for relief of radicular pain. In addition, the patient population presenting for this procedure has a high propensity for preoperative narcotic use. PURPOSE: The study aims to identify an association between preoperative tramadol abuse and clinical outcome after lumbar discectomy. STUDY DESIGN: A descriptive controlled, non-randomized, clinical study. PATIENTS AND METHODS: Sixty patients underwent surgery for lumbar disc herniation. They were divided into two groups; control group and tramadol abuse group. Each group included 30 patients. They were operated between 2015 and 2016. Participants were evaluated pre-operatively and post-operatively every three months. Strict history taking regarding preoperative and postoperative pain medication utilization, operative time, hospital stay and complications were assessed. Pain was scored by a VAS for both lower limbs and back pain. The clinical outcomes were compared using the Prolo economic and functional rating scale. RESULTS: In Tramadol abuse group, 12 (40%) continued to use tramadol after surgery. Tramadol abuse group showed worse clinical outcome parameters including worse VAS for low back pain and lower limb pain, worse Prolo economic, functional rating scale. In addition, tramadol abuse group showed significantly higher complications rate in the early post-operative and during the follow up period. CONCLUSION: Tramadol abuse before lumbar discectomy was found to be associated with continued tramadol abuse after surgery and worse functional outcomes following surgery. Surgeons may want to counsel their patients about the potential for inferior clinical outcomes if narcotics were used before surgery.


Assuntos
Discotomia , Vértebras Lombares/cirurgia , Transtornos Relacionados com Narcóticos/complicações , Entorpecentes/efeitos adversos , Tramadol/efeitos adversos , Adulto , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Estudos de Casos e Controles , Discotomia/efeitos adversos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
17.
Clin Spine Surg ; 32(10): E440-E443, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31145151

RESUMO

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To identify the differences in inpatient pain scores, narcotic consumption, and patient-reported outcomes (PROs) between tobacco users and nonusers following an anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Previous studies have investigated tobacco use as a risk factor for negative postsurgical outcomes following spine surgery; however, few studies have analyzed the effects of tobacco on pain following ACDF. METHODS: Patients undergoing primary, 1-level, or 2-level ACDF were retrospectively reviewed and stratified by tobacco use at the time of surgery. Inpatient pain scores and narcotic consumption were collected. Neck Disability Index and Visual Analogue Scale (VAS) neck and arm pain scores were collected preoperatively and at 6-week, 3-month, and 6-month follow-up visits. Differences in demographics and perioperative characteristics were assessed using χ analysis and multivariate linear regression. An association between immediate postoperative pain, narcotics consumption, and long-term PROs was tested for using multivariate linear regression. RESULTS: A total of 192 patients were included and stratified by tobacco use: tobacco (n=25) and nontobacco (n=167). There were no significant differences in demographic and perioperative characteristics. No statistical differences were observed in inpatient VAS pain scores and narcotic consumption on postoperative day 0 and postoperative day 1. Preoperative VAS neck pain and arm pain was greater in tobacco users, however, improvements in neck and arm pain were similar in the postoperative period through 6-month follow-up. In addition, no statistical differences in Neck Disability Index were observed preoperatively or at any postoperative time points. CONCLUSIONS: Our study suggests that tobacco use does not influence inpatient pain scores, narcotic consumption, and improvements in PROs following ACDF. As such, tobacco users and nonusers should receive similar postoperative pain management protocols following surgery. LEVEL OF EVIDENCE: Level III.


Assuntos
Vértebras Cervicais/cirurgia , Discotomia/efeitos adversos , Dor Pós-Operatória/etiologia , Fusão Vertebral/efeitos adversos , Uso de Tabaco/efeitos adversos , Feminino , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Entorpecentes/efeitos adversos , Medidas de Resultados Relatados pelo Paciente , Assistência Perioperatória
18.
BMJ Case Rep ; 12(5)2019 May 27.
Artigo em Inglês | MEDLINE | ID: mdl-31133548

RESUMO

A 72-year-old woman with suicidal ideations for the first time was seen for a follow-up medical visit. Patient diagnosed with bipolar disorder II, chronic complex pain and other complex medical issues. Patient was on long-standing chronic opioid agonist therapy. Patient was prescribed oral hydromorphone to supplement her chronic opioid regimen. Within 24 hours, the patient reported no further suicidal ideations and there were no reported complications. The case provides impetus for further study as to what interventions work best for patients who present with acute suicidal ideations. The case acknowledges cultural issues and implicit biases that can influence medical care and perceptions thereof. Implicit biases may be particularly apparent as they relate to mental health concerns and the use of substances that are susceptible to abuse. The most important clinical lesson reminder may be the importance of adequate documentation and discussion be provided when one prescribes an opioid in a novel way in a special clinical context.


Assuntos
Transtorno Bipolar/psicologia , Dor Crônica/tratamento farmacológico , Hidromorfona/efeitos adversos , Tentativa de Suicídio/prevenção & controle , Idoso , Transtorno Bipolar/complicações , Transtorno Bipolar/diagnóstico , Dor Crônica/complicações , Dor Crônica/psicologia , Depressão/tratamento farmacológico , Depressão/psicologia , Feminino , Humanos , Hidromorfona/administração & dosagem , Hidromorfona/uso terapêutico , Entorpecentes/efeitos adversos , Ideação Suicida , Tentativa de Suicídio/psicologia , Resultado do Tratamento
19.
J Arthroplasty ; 34(8): 1662-1666, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31076193

RESUMO

BACKGROUND: The 2013 American Academy of Orthopedic Surgeons evidence-based guidelines recommend against the use of preoperative narcotics in the management of symptomatic osteoarthritic knees; however, the guidelines strongly recommend tramadol in this patient population. To our knowledge, no study to date has evaluated outcomes in patients who use tramadol exclusively as compared with narcotics naive patients. METHODS: This is a retrospective study of prospectively collected data for patients who underwent unilateral primary total knee arthroplasty between January 2017 and March 2018. PRO scores were obtained using a novel electronic patient rehabilitation application, which pushed PRO surveys via email and mobile devices within 1 month prior to surgery and 3 months postoperatively. RESULTS: One hundred and thirty-six patients were opiate naïve, while 63 had obtained narcotics before the index operation. Of those, 21 patients received tramadol. The average preoperative Knee Disability and Osteoarthritis Outcome Scores were 50.4, 49.95, and 48.01 for the naïve, tramadol, and narcotic populations, respectively, (P = .60). The tramadol cohort had the least gain in 3 months postoperative Knee Disability and Osteoarthritis Outcome Scores, improving on average 12.5 points in comparison to the 19.1 and 20.1 improvements seen in the narcotic and naïve cohorts, respectively (P = .09). This difference was statistically significant when comparing the naïve and tramadol populations alone in post hoc analysis (P = .016). CONCLUSIONS: When comparing patients who took tramadol preoperatively to patients who were opiate naïve, patients that used tramadol trended toward significantly less improvement in functional outcomes in the short-term postoperative period.


Assuntos
Artroplastia do Joelho/efeitos adversos , Osteoartrite do Joelho/cirurgia , Tramadol/efeitos adversos , Idoso , Analgésicos Opioides/efeitos adversos , Feminino , Humanos , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Entorpecentes/efeitos adversos , Osteoartrite do Joelho/fisiopatologia , Avaliação de Resultados em Cuidados de Saúde , Medidas de Resultados Relatados pelo Paciente , Período Pós-Operatório , Estudos Retrospectivos , Resultado do Tratamento
20.
J Perinatol ; 39(6): 848-856, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30940929

RESUMO

OBJECTIVE: To determine the impact of premedication for tracheal intubation (TI) on adverse TI associated events, severe oxygen desaturations, and first attempt success STUDY DESIGN: Retrospective cohort study in neonatal intensive care units (NICU) participating in the National Emergency Airway Registry for Neonates from 10/2014 to 6/2017. Premedication for TI was categorized as sedation with neuromuscular blockade, sedation only, or no medication. RESULTS: 2260 TIs were reported from 11 NICUs. Adverse TI associated events occurred less often in sedation with neuromuscular blockade group (10%) as compared to sedation only (29%), or no medication group (23%), p < 0.001. The adjusted odds ratio (aOR) for adverse TI associated events were: sedation with neuromuscular blockade aOR 0.48 (95%CI 0.34-0.65, p < 0.001) compared to no medication. CONCLUSION: Use of sedation with neuromuscular blockade was associated with favorable TI outcomes. This study supports the recommendation for the standard use of sedation with neuromuscular blockade in non-emergency TIs.


Assuntos
Intubação Intratraqueal/efeitos adversos , Bloqueio Neuromuscular/métodos , Pré-Medicação/métodos , Estudos de Casos e Controles , Fentanila/administração & dosagem , Fentanila/efeitos adversos , Humanos , Hipnóticos e Sedativos/administração & dosagem , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Intubação Intratraqueal/métodos , Midazolam/administração & dosagem , Midazolam/efeitos adversos , Morfina/administração & dosagem , Morfina/efeitos adversos , Entorpecentes/administração & dosagem , Entorpecentes/efeitos adversos , Bloqueio Neuromuscular/efeitos adversos , Consumo de Oxigênio/efeitos dos fármacos , Estudos Retrospectivos
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