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1.
JAMA Psychiatry ; 79(1): 13-23, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34586357

RESUMO

Importance: Chronic back pain (CBP) is a leading cause of disability, and treatment is often ineffective. Approximately 85% of cases are primary CBP, for which peripheral etiology cannot be identified, and maintenance factors include fear, avoidance, and beliefs that pain indicates injury. Objective: To test whether a psychological treatment (pain reprocessing therapy [PRT]) aiming to shift patients' beliefs about the causes and threat value of pain provides substantial and durable pain relief from primary CBP and to investigate treatment mechanisms. Design, Setting, and Participants: This randomized clinical trial with longitudinal functional magnetic resonance imaging (fMRI) and 1-year follow-up assessment was conducted in a university research setting from November 2017 to August 2018, with 1-year follow-up completed by November 2019. Clinical and fMRI data were analyzed from January 2019 to August 2020. The study compared PRT with an open-label placebo treatment and with usual care in a community sample. Interventions: Participants randomized to PRT participated in 1 telehealth session with a physician and 8 psychological treatment sessions over 4 weeks. Treatment aimed to help patients reconceptualize their pain as due to nondangerous brain activity rather than peripheral tissue injury, using a combination of cognitive, somatic, and exposure-based techniques. Participants randomized to placebo received an open-label subcutaneous saline injection in the back; participants randomized to usual care continued their routine, ongoing care. Main Outcomes and Measures: One-week mean back pain intensity score (0 to 10) at posttreatment, pain beliefs, and fMRI measures of evoked pain and resting connectivity. Results: At baseline, 151 adults (54% female; mean [SD] age, 41.1 [15.6] years) reported mean (SD) pain of low to moderate severity (mean [SD] pain intensity, 4.10 [1.26] of 10; mean [SD] disability, 23.34 [10.12] of 100) and mean (SD) pain duration of 10.0 (8.9) years. Large group differences in pain were observed at posttreatment, with a mean (SD) pain score of 1.18 (1.24) in the PRT group, 2.84 (1.64) in the placebo group, and 3.13 (1.45) in the usual care group. Hedges g was -1.14 for PRT vs placebo and -1.74 for PRT vs usual care (P < .001). Of 151 total participants, 33 of 50 participants (66%) randomized to PRT were pain-free or nearly pain-free at posttreatment (reporting a pain intensity score of 0 or 1 of 10), compared with 10 of 51 participants (20%) randomized to placebo and 5 of 50 participants (10%) randomized to usual care. Treatment effects were maintained at 1-year follow-up, with a mean (SD) pain score of 1.51 (1.59) in the PRT group, 2.79 (1.78) in the placebo group, and 3.00 (1.77) in the usual care group. Hedges g was -0.70 for PRT vs placebo (P = .001) and -1.05 for PRT vs usual care (P < .001) at 1-year follow-up. Longitudinal fMRI showed (1) reduced responses to evoked back pain in the anterior midcingulate and the anterior prefrontal cortex for PRT vs placebo; (2) reduced responses in the anterior insula for PRT vs usual care; (3) increased resting connectivity from the anterior prefrontal cortex and the anterior insula to the primary somatosensory cortex for PRT vs both control groups; and (4) increased connectivity from the anterior midcingulate to the precuneus for PRT vs usual care. Conclusions and Relevance: Psychological treatment centered on changing patients' beliefs about the causes and threat value of pain may provide substantial and durable pain relief for people with CBP. Trial Registration: ClinicalTrials.gov Identifier: NCT03294148.


Assuntos
Dor nas Costas/terapia , Manejo da Dor/métodos , Manejo da Dor/normas , Dor/etiologia , Adulto , Dor nas Costas/psicologia , Avaliação da Deficiência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor/psicologia , Manejo da Dor/estatística & dados numéricos , Resultado do Tratamento
2.
Surgery ; 171(2): 453-458, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34538340

RESUMO

BACKGROUND: The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum-endorsed measures. Postoperative pain is an important clinical timepoint because poor pain control can lead to patient suffering, chronic opiate use, and/or chronic pain. Quality measures can guide best practices, but it is unclear whether there are measures for managing pain after surgery. METHODS: The National Quality Forum Quality Positioning System, Agency for Healthcare Research and Quality Indicators, and Centers for Medicare and Medicaid Services Measures Inventory Tool databases were searched in November 2019. We conducted a systematic literature review to further identify quality measures in research publications, clinical practice guidelines, and gray literature for the period between March 11, 2015 and March 11, 2020. RESULTS: Our systematic review yielded 1,328 publications, of which 206 were pertinent. Nineteen pain management quality measures were identified from the quality measure databases, and 5 were endorsed by National Quality Forum. The National Quality Forum measures were not specific to postoperative pain management. Three of the non-endorsed measures were specific to postoperative pain. CONCLUSION: The dearth of published postoperative pain management quality measures, especially National Quality Forum-endorsed measures, highlights the need for more rigorous evidence and widely endorsed postoperative pain quality measures to guide best practices.


Assuntos
Manejo da Dor/estatística & dados numéricos , Dor Pós-Operatória/terapia , Padrões de Prática Médica/estatística & dados numéricos , Lacunas da Prática Profissional/estatística & dados numéricos , Centers for Medicare and Medicaid Services, U.S./estatística & dados numéricos , Bases de Dados Factuais/estatística & dados numéricos , Humanos , Medicare/estatística & dados numéricos , Manejo da Dor/normas , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/organização & administração , Estados Unidos , United States Agency for Healthcare Research and Quality/estatística & dados numéricos
3.
Anaesthesia ; 77(3): 311-325, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34739134

RESUMO

Video-assisted thoracoscopic surgery has become increasingly popular due to faster recovery times and reduced postoperative pain compared with thoracotomy. However, analgesic regimens for video-assisted thoracoscopic surgery vary significantly. The goal of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after video-assisted thoracoscopic surgery. A systematic review was undertaken using procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials published in the English language, between January 2010 and January 2021 assessing the effect of analgesic, anaesthetic or surgical interventions were identified. We retrieved 1070 studies of which 69 randomised controlled trials and two reviews met inclusion criteria. We recommend the administration of basic analgesia including paracetamol and non-steroidal anti-inflammatory drugs or cyclo-oxygenase-2-specific inhibitors pre-operatively or intra-operatively and continued postoperatively. Intra-operative intravenous dexmedetomidine infusion may be used, specifically when basic analgesia and regional analgesic techniques could not be given. In addition, a paravertebral block or erector spinae plane block is recommended as a first-choice option. A serratus anterior plane block could also be administered as a second-choice option. Opioids should be reserved as rescue analgesics in the postoperative period.


Assuntos
Analgésicos/administração & dosagem , Bloqueio Nervoso/normas , Manejo da Dor/normas , Dor Pós-Operatória/prevenção & controle , Guias de Prática Clínica como Assunto/normas , Cirurgia Torácica Vídeoassistida/métodos , Analgésicos Opioides/administração & dosagem , Anti-Inflamatórios não Esteroides/administração & dosagem , Quimioterapia Combinada , Humanos , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/normas , Cirurgia Torácica Vídeoassistida/efeitos adversos
4.
Surgery ; 171(2): 504-510, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34740455

RESUMO

BACKGROUND: Enhanced Recovery After Surgery programs have been shown to effectively reduce opioid prescriptions at discharge after their implementation in several institutions, but little is known regarding the sustainability of this effect. Understanding opioid prescribing patterns after long-term implementation of Enhanced Recovery After Surgery initiatives may help guide further opioid prescription reduction and improvements. Our group aimed to determine whether reductions in opioid prescriptions at discharge are sustained in an Enhanced Recovery After Surgery program for thoracic surgery. METHODS: This retrospective cohort included 2,081 patients undergoing thoracic surgery within a 4-year Enhanced Recovery After Surgery program from March 2016 through April 2020. Our Enhanced Recovery After Surgery protocol included a standardized multimodal analgesic regimen (ie, preoperative gabapentin, tramadol, intercostal nerve block with liposomal bupivacaine, and intraoperative acetaminophen, and ketorolac) and the rest of the interventions recommended by the Enhanced Recovery After Surgery society guidelines. Our primary outcomes were the presence of opioid prescriptions at discharge (hydrocodone, hydromorphone, and oxycodone) and the total opioid amount prescribed (morphine equivalent daily dose). Multilevel generalized linear models were used to account for surgeon variabilities and types of thoracic resection. RESULTS: Over the study period, the rate of opioid prescriptions at discharge reduced from 35% (Mar 2016) to 25% (Apr 2020), and the amount of opioid prescribed declined from 184 ± 321 morphine equivalent daily dose to 94 ± 251 morphine equivalent daily dose. In multilevel generalized linear models, there was a sustained downward trend in opioid prescriptions over the study period (ß -11.8 morphine equivalent daily dose per year, P = .048), which was also directly correlated with the use of minimally invasive surgery (ß -84.9 morphine equivalent daily dose for video-assisted thoracoscopic surgery, P < .001; ß -139.2 morphine equivalent daily dose for robotic-assisted thoracic surgery, P < .001), intraoperative opioid administration (ß -1.4 morphine equivalent daily dose per 1 morphine equivalent dose, P = .026), and the amount of postoperative acetaminophen (ß -18.2 morphine equivalent daily dose per 1 g, P = .026). The sustained reduction of opioid prescriptions at discharge did not impact hospital readmission rates within 30 days (odds ratio 1.17, 95% confidence interval 0.86-1.59, P = .306). Subgroup analysis showed a significant, sustained decrease in hydromorphone (ß -10.9 morphine equivalent daily dose per year, P = .004), but not for hydrocodone prescriptions (ß -5.7 morphine equivalent daily dose per year, P = .168) or oxycodone (ß +4.78 morphine equivalent daily dose per year, P = .183). CONCLUSION: Our Enhanced Recovery After Surgery program for thoracic surgery contributed to a sustained reduction of opioid prescriptions at discharge, which positively correlated with the duration of its implementation and the use of minimally invasive surgical techniques but was negatively impacted by the amount of intraoperative opioid administration.


Assuntos
Analgésicos Opioides/efeitos adversos , Recuperação Pós-Cirúrgica Melhorada , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Idoso , Prescrições de Medicamentos/normas , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Epidemia de Opioides/prevenção & controle , Manejo da Dor/normas , Manejo da Dor/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos
5.
PLoS One ; 16(12): e0261018, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34882705

RESUMO

INTRODUCTION: Clinical record (CR) is the primary tool used by healthcare workers (HCWs) to record clinical information and its completeness can help achieve safer practices. CR is the most appropriate source in order to measure and evaluate the quality of care. In order to achieve a safety climate is fundamental to involve a responsive healthcare workforce thorough peer-review and feedbacks. This study aims to develop a peer-review tool for clinical records quality assurance, presenting the seven-year experience in the evolution of it; secondary aims are to describe the CR completeness and HCWs' diligence toward recording information in it. METHODS: To assess the completeness of CRs a peer-review tool was developed in a large Academic Hospital of Northern Italy. This tool included measurable items that examined different themes, moments and levels of the clinical process. Data were collected every three months between 2010 and 2016 by appointed and trained HCWs from 42 Units; the hospital Quality Unit was responsible for of processing and validating them. Variations in the proportion of CR completeness were assessed using Cochran-Armitage test for trends. RESULTS: A total of 9,408 CRs were evaluated. Overall CR completeness improved significantly from 79.6% in 2010 to 86.5% in 2016 (p<0.001). Doctors' attitude showed a trend similar to the overall completeness, while nurses improved more consistently (p<0.001). Most items exploring themes, moments and levels registered a significant improvement in the early years, then flattened in last years. Results of the validation process were always above the cut-off of 75%. CONCLUSIONS: This peer-review tool enabled the Quality Unit and hospital leadership to obtain a reliable picture of CRs completeness, while involving the HCWs in the quality evaluation. The completeness of CR showed an overall positive and significant trend during these seven years.


Assuntos
Centros Médicos Acadêmicos/normas , Documentação/normas , Registros Eletrônicos de Saúde/normas , Sistemas de Informação Hospitalar/normas , Manejo da Dor/normas , Garantia da Qualidade dos Cuidados de Saúde/normas , Melhoria de Qualidade/normas , Anestesia/normas , Humanos
7.
Arch Pediatr ; 28(7): 544-547, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34593294

RESUMO

OBJECTIVES: We aimed to evaluate the efficacy of fascia iliaca nerve block (FINB), routinely used for children with femoral fractures, in a pediatric emergency department (PED). METHODS: This retrospective, single-center, observational study examined FINB using ropivacaine and a 1% lidocaine hydrochloride solution, in all patients under 18 years of age admitted with a femoral fracture from January 2012 to December 2016. Pain was assessed using two validated pediatric pain scales: EVENDOL or a visual analog scale. A level of ≥ 4 on either scale indicates the need for an analgesic. The primary outcome was the percentage of patients who were pain free after the FINB procedure defined by a pain score of < 4. Secondary outcomes were the time spent between PED admission and FINB, the need of additional analgesics, side effects, and the success rate of FINB. RESULTS: Of 161 patients screened, 144 were included. The median age was 3.2 years (range 2 months to 16 years) and 74% were boys. The number of children determined to be pain free (pain score < 4) increased from 36 (25%) before the FINB to 123 (85%) after the FINB (absolute risk difference 60%, 95% CI: 51%-70%). Overall, 21 children (15%) required a second analgesic after the FINB. CONCLUSION: The routine use of FINB with ropivacaine and lidocaine by pediatric ED physicians provided effective pain relief for children admitted for a femoral fracture in the emergency department. Our data support the efficiency and feasibility of FINB for the antalgic management of children with femoral fracture.


Assuntos
Fraturas do Fêmur/tratamento farmacológico , Bloqueio Nervoso/normas , Adolescente , Criança , Pré-Escolar , Feminino , Fraturas do Fêmur/fisiopatologia , França , Humanos , Lactente , Masculino , Bloqueio Nervoso/métodos , Bloqueio Nervoso/estatística & dados numéricos , Manejo da Dor/métodos , Manejo da Dor/normas , Manejo da Dor/estatística & dados numéricos , Medição da Dor/métodos , Estudos Retrospectivos
8.
South Med J ; 114(10): 623-629, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34599339

RESUMO

OBJECTIVES: Opioid receipt during medical hospitalizations may be associated with subsequent long-term use. Studies, however, have not accounted for pain, which may explain chronic use. The objective of this study was to identify the association between opioid exposure during a medical hospitalization and use 6 to 12 months later. METHODS: This was an observational cohort study using electronic health record data from 10 hospitals in the Cleveland Clinic Health System in 2016. Eligible patients were opioid-naïve adults with pain age 18 years and older, admitted to a medical service. Outcomes were opioid receipt during hospitalization and on discharge, and long-term opioid use, defined as ≥2 prescriptions for at least 30 pills 6 to 12 months posthospitalization. We estimated the odds of long-term opioid use by opioid exposure during the hospitalization. Models controlled for patient demographic and clinical characteristics, including patient-reported pain. RESULTS: Among the 2971 patients in the sample, 64% received opioids during their hospitalization and 28% were discharged with opioids. Overall, 3% of patients had long-term use. Higher pain score was associated with greater odds of long-term use (adjusted odds ratio [aOR] per point increase 1.11; 95% confidence interval [CI] 1.03-1.19). No patient factors were associated with long-term use. Receipt of an opioid during a hospitalization only was not associated with long-term use (aOR 1.44, 95% CI 0.81-2.57), but receipt at discharge was (aOR 1.96, 95% CI 1.08-3.56). CONCLUSIONS: Although opioid receipt at discharge was associated with long-term use, the number of patients this applied to was small. Pain severity was an important predictor of long-term use and should be accounted for in future studies.


Assuntos
Analgésicos Opioides/administração & dosagem , Prescrições de Medicamentos/estatística & dados numéricos , Pacientes Internados/estatística & dados numéricos , Manejo da Dor/métodos , Adulto , Idoso , Estudos de Coortes , Feminino , Hospitalização/estatística & dados numéricos , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Ohio , Manejo da Dor/normas , Manejo da Dor/estatística & dados numéricos , Estudos Retrospectivos , Tempo
9.
Medicine (Baltimore) ; 100(38): e27245, 2021 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-34559126

RESUMO

ABSTRACT: When developing a new medical device, it is essential to assess the usability of such a device through various stakeholders.This study assessed the usability of pain medical devices through a Delphi survey administered to physiatrists and physiotherapists.A Delphi survey was conducted on the problems and improvements in hardware and software for a panel consisting of 10 physiatrists and 10 physiotherapists. A total of 3 rounds of surveys were conducted, and the third round of survey was confirmed through a Likert scale (1 = strongly agree to 5 = strongly disagree).The 2 groups generally had a common perception of the problems and improvements in pain medical devices. However, the physiatrist group mostly identified problems such as linking patient information, whereas the physiotherapist group deemed hardware problems such as device weight or connection cables as being more important (mean [standard deviation]; physiatrist, hardware 2.90 [0.93], software 2.28 [0.91] / physiotherapist, hardware 3.04 [0.84], software 3.03 [1.13]).To date, analysis has not been conducted by dividing the focus of various stakeholders using pain medical devices. The difference in view of the usability of these 2 stakeholder groups should be considered when improving the hardware or software of pain medical devices in the future. Further research is warranted to investigate other stakeholders such as patients and device developers to improve the devices.


Assuntos
Desenho de Equipamento/normas , Manejo da Dor/instrumentação , Design Centrado no Usuário , Adulto , Técnica Delfos , Desenho de Equipamento/estatística & dados numéricos , Feminino , Humanos , Masculino , Manejo da Dor/normas , Manejo da Dor/tendências , Fisiatras/tendências , Fisioterapeutas/tendências , República da Coreia , Estatísticas não Paramétricas , Inquéritos e Questionários
10.
Pharmacogenomics ; 22(14): 927-937, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34521258

RESUMO

Opioid misuse and mismanagement has been a public health crisis for several years. Pharmacogenomics (PGx) has been proposed as another tool to enhance opioid selection and optimization, with recent studies demonstrating successful implementation and outcomes. However, broad engagement with PGx for opioid management is presently limited. The purpose of this article is to highlight a series of barriers to PGx implementation within the specific context of opioid management. Areas of advancement needed for more robust pharmacogenomic engagement with opioids will be discussed, including clinical and economic research needs, education and training needs, policy and public health considerations, as well as legal and ethical issues. Continuing efforts to address these issues may help to further operationalize PGx toward improving opioid use.


Assuntos
Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Manejo da Dor/normas , Farmacogenética/normas , Guias de Prática Clínica como Assunto/normas , Prática de Saúde Pública/normas , Analgésicos Opioides/efeitos adversos , Humanos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Dor/tratamento farmacológico , Dor/epidemiologia , Manejo da Dor/ética , Farmacogenética/métodos , Prática de Saúde Pública/ética , Prática de Saúde Pública/legislação & jurisprudência
12.
J Clin Epidemiol ; 139: 167-176, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34400254

RESUMO

OBJECTIVE: To examine pain treatment preferences before and after participation in an N-of-1 trial. STUDY DESIGN AND SETTING: In this observational study nested within a randomized trial, we examined chronic pain patients' preferences before and after treatment in relation to N-of-1 trial results; assessed the influence of different schemes for defining comparative "superiority" on potential conclusions; and generated classification trees illustrating the relationship between pre-treatment preferences, N-of-1 trial results, and post-treatment preferences. RESULTS: Treatment preferences differed pre- and post-trial for 40% of participants. The proportion of patients whose N-of-1 trials demonstrated "superiority" of one treatment regimen over the other varied depending on how superiority was defined and ranged from 24% (using criteria that required statistically significant differences between regimens) to 62% (when relying only on differences in point estimates). Regardless of criteria for declaring treatment superiority, nearly three-fourths of patients with equivocal N-of-1 trial results nevertheless expressed definite preferences post-trial. CONCLUSION: A large segment of patients undergoing N-of-1 trials for chronic pain altered their treatment preferences. However, the direction of preference change did not necessarily correspond to the N-of-1 results. More research is needed to understand how patients use N-of-1 trial results, why preferences are "sticky" even in the face of personalized data, and how patients and clinicians might be educated to use N-of-1 trial results more informatively.


Assuntos
Analgésicos/uso terapêutico , Dor Crônica/tratamento farmacológico , Dor Musculoesquelética/tratamento farmacológico , Manejo da Dor/métodos , Manejo da Dor/normas , Preferência do Paciente/psicologia , Preferência do Paciente/estatística & dados numéricos , Idoso , Tomada de Decisão Compartilhada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/estatística & dados numéricos
13.
Nurs Res ; 70(6): 469-474, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34262006

RESUMO

BACKGROUND: Very little research has been reported examining nonpharmacological symptom management strategies for very young, hospitalized children receiving palliative care, and none has involved Reiki-a light touch therapy. OBJECTIVES: The aim of this study was to determine if completing a Reiki intervention with hospitalized 1- to 5-year-old children with chronic, life-limiting conditions receiving palliative care was feasible and acceptable. METHODS: Children ages 1-5 years receiving palliative care who were expected to be hospitalized for at least 3 weeks were recruited for a single-arm, mixed-methods, quasi-experimental pre- and poststudy. Six protocolized Reiki sessions were conducted over 3 weeks. We calculated feasibility by the percentage of families enrolled in the study and acceptability by the percentage of families who completed all measures and five out of six Reiki sessions. Measures were collected at baseline, at the end of the intervention period, and 3 weeks later. At the final follow-up visit, parents were verbally asked questions relating to the acceptability of the intervention in a short structured interview. RESULTS: We screened 90 families, approached 31 families, and recruited 16 families, whereas 15 families declined. Reasons for not participating included that the child had "a lot going on," would be discharged soon, and families were overwhelmed. Of those enrolled, most completed all measures at three time points and five out of six Reiki sessions. We completed nearly all scheduled Reiki sessions for families that finished the study. All parents reported that they would continue the Reiki if they could, and almost all said they would participate in the study again; only one parent was unsure. DISCUSSION: Young children and their parents found Reiki acceptable; these results are comparable to an earlier study of children 7-16 years of age receiving palliative care at home and a study of massage for symptom management for hospitalized children with cancer. These findings add to the literature and support further investigation of Reiki's efficacy as a nonpharmacological symptom management intervention.


Assuntos
Massagem/normas , Manejo da Dor/normas , Cuidados Paliativos/normas , Pediatria/normas , Guias de Prática Clínica como Assunto , Toque Terapêutico/normas , Adolescente , Fatores Etários , Criança , Pré-Escolar , Estudos de Viabilidade , Feminino , Humanos , Lactente , Masculino
14.
JAMA Netw Open ; 4(7): e2116860, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34255047

RESUMO

Importance: The Centers for Disease Control and Prevention (CDC) released the "Guideline For Prescribing Opioids For Chronic Pain" (hereafter, CDC guideline) in 2016, but its association with prescribing practices for patients who are opioid naive is unknown. Objective: To estimate changes in initial prescribing rates, duration, and dosage practices to patients who are opioid naive after the release of the CDC guideline. Design, Setting, and Participants: This cohort study used 6 sequential cohorts to estimate preguideline trends in prescribing among patients who were opioid naive, project that trend forward, and compare it with postguideline prescribing practices. Participants included commercially insured adults without current cancer or hospice care diagnoses and with no past-year opioid claims in the US from 2011 to 2017. All adjusted models were controlled for patient demographics and state-fixed effects. Data were analyzed from January 2020 to May 2021. Exposures: The release of the CDC guideline. Main Outcomes and Measures: Indicators of any opioid prescription fills during a 9-month period, the number of days' supply of the initial prescription, and the binary indicator of whether the initial prescription was for 50 or more morphine milligram equivalents (MMEs) per day. Results: There were 12 870 612 eligible unique patients across cohorts (mean [SD] age in 2016, 51.2 [18.7] years; 6 553 458 [50.9%] women); and the mean (SD) age of the cohorts increased annually, from 48.7 (17.9) years in the April 2011 to December 2012 cohort to 51.9 (19.2) years in the April 2016 to December 2017 cohort. The postguideline prescribing prevalence was 532 962 of 5 834 088 individuals (9.1%), which exceeded that projected from the preguideline trend, estimated at 9.0% (95% CI, 9.0%-9.1%). Among patients receiving prescriptions during follow-up, adjusted mean days' supply was 4.7% (95% CI, 4.3%-5.1%) lower in the first year after release of the guideline and 9.8% (95% CI, 9.3%-10.3%) lower in the second year after release, compared with the expected rate from the preguideline trend. The adjusted odds of receiving a high-dose (ie, ≥50 MME/d) initial prescription were lower in the first year (odds ratio, 0.97; 95% CI, 0.96-0.98) and in the second year (odds ratio, 0.94; 95% CI, 0.93-0.96) after the release of the CDC guideline compared with the odds expected from the preguideline trend. Conclusions and Relevance: This cohort study found that patients who were opioid naive continued to initiate opioid therapy after the release of opioid prescribing guidelines by the CDC, but trends in prescribing duration reversed and decreased, after increasing in each of 4 preguideline cohorts examined. High-dose prescribing rates were already decreasing, but those trends accelerated after the CDC guideline release. These results suggest that nonmandatory, evidence-based guidelines from trusted sources were associated with prescribing practices. Guideline-concordant care has potential to improve pain management and reduce opioid-related harms.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Prescrições de Medicamentos/estatística & dados numéricos , Manejo da Dor/tendências , Padrões de Prática Médica/tendências , Adulto , Centers for Disease Control and Prevention, U.S. , Estudos de Coortes , Esquema de Medicação , Prescrições de Medicamentos/normas , Feminino , Implementação de Plano de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Manejo da Dor/normas , Padrões de Prática Médica/normas , Estados Unidos
15.
Am J Perinatol ; 38(13): 1341-1347, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34282576

RESUMO

OBJECTIVE: This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use. STUDY DESIGN: We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge. RESULTS: Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90-195] PRE to 114 [range: 45-168] POST (p = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5-8] vs. POST 5 [range: 3-7], p < 0.001). The median number of pills consumed after discharge also decreased significantly (PRE: 25 [range: 16-30] vs. POST 17.5 [range: 4-25], p = 0.001). The number of pills consumed was significantly associated with number prescribed (p < 0.001). The median number of leftover pills and number of refills did not significantly differ between groups. Median patient-reported pain scores at the week after discharge were lower in the POST group (PRE: 4 [range: 2-6] vs. POST 3[range: 1-5], p = 0.03). CONCLUSION: Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients. KEY POINTS: · An ERAS-CD pathway was associated with decreased opioid use.. · Outpatient opioid consumption after cesarean warrants further study.. · Physician prescribing drives patients' opioid consumption..


Assuntos
Analgésicos não Narcóticos/uso terapêutico , Analgésicos Opioides/uso terapêutico , Cesárea/efeitos adversos , Oxicodona/uso terapêutico , Manejo da Dor/normas , Dor Pós-Operatória/tratamento farmacológico , Centros Médicos Acadêmicos , Adulto , Procedimentos Clínicos , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Manejo da Dor/métodos , Medição da Dor , Adulto Jovem
16.
Clin J Oncol Nurs ; 25(4): 361-362, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-34269344

RESUMO

Now that the SARS-CoV-2 virus and its variants have altered clinical oncology practice as we know it, let's return to a familiar focus from the Core Curriculum for Oncology Nursing-pain management. Much has happened during the past two years that influences the effective management of pain in patients with cancer-not the least of which is a clinical environment that has been changed by the COVID-19 pandemic.


Assuntos
Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , COVID-19/epidemiologia , Dor do Câncer/tratamento farmacológico , Oncologia/normas , Enfermagem Oncológica/normas , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Manejo da Dor/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Guias de Prática Clínica como Assunto , SARS-CoV-2 , Estados Unidos/epidemiologia
17.
Medicine (Baltimore) ; 100(23): e26225, 2021 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-34115008

RESUMO

BACKGROUND: Lung cancer (LC) is the malignant tumor with the highest incidence in the world, and treatment methods include surgery, radiotherapy, chemotherapy, and immunotherapy. Cancer pain is a common symptom in patients with LC, and the clinical treatment is to relieve it with analgesics. Acupuncture can relieve cancer pain. This study aims to systematically study the efficacy and safety of acupuncture combined with analgesics on cancer pain in patients with LC. METHODS: From the beginning to April 2021, search Medline, Embase, Cochrane Central Controlled Trials Register (Central), China National Knowledge Infrastructure (CNKI), Wanfang Database, China Biomedical Literature Database (CBM), and Chinese Science Journal Database (VIP database). Search the international clinical trial registration platform and the Chinese clinical trial registration platform to find ongoing or unpublished trials. The main outcome indicator is the total effective rate of analgesia, and the secondary outcome indicator is pain intensity score and adverse reactions. The RevMan 5.4 software will be used for statistical analysis. RESULTS: This study will provide the latest evidence for acupuncture combined with analgesics to relieve LC pain. CONCLUSION: The conclusion of this study is to evaluate the effectiveness and safety of acupuncture combined with analgesics in alleviating LC pain. INPLASY REGISTRATION NUMBER: INPLASY202150051.


Assuntos
Terapia por Acupuntura/normas , Analgésicos/normas , Dor do Câncer/terapia , Protocolos Clínicos , Manejo da Dor/normas , Terapia por Acupuntura/métodos , Analgésicos/uso terapêutico , Dor do Câncer/tratamento farmacológico , Terapia Combinada/métodos , Terapia Combinada/normas , Humanos , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/terapia , Manejo da Dor/métodos , Segurança do Paciente/normas , Resultado do Tratamento
18.
Holist Nurs Pract ; 35(4): 182-190, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34115736

RESUMO

Chronic low back pain (CLBP) is a major problem throughout the world and getting worse because of population increase and aging. The cost of treatment increases as the population of people with CLBP increases. This study aimed to examine the effect of auricular acupressure (AA) on pain and disability in elders with chronic low back pain. The randomized, single-blinded, and placebo-controlled study was conducted on 51 elders with CLBP in South Korea from June 2019 to August 2019. The experimental group (n = 26) received AA on low back pain-related points, whereas the placebo control group (n = 25) received AA on points unrelated to low back pain. Participants received 6 weeks of AA in weekly cycles. Collected data were analyzed using IBM SPSS Statistics, version 25. Statistically significant differences between the 2 groups emerged in the visual analog scale (P < .001), pain threshold (P < .001), and Oswestry Disability Index (P < .001). This study showed that 6 weeks of AA improved CLBP and pain-related disability. Therefore, AA can be used as a noninvasive and self-managed alternative intervention for CLBP in older adults.


Assuntos
Acupressão/métodos , Orelha/inervação , Dor Lombar/terapia , Acupressão/tendências , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Dor Lombar/fisiopatologia , Masculino , Manejo da Dor/métodos , Manejo da Dor/normas , Manejo da Dor/estatística & dados numéricos , Medição da Dor/métodos , República da Coreia , Método Simples-Cego , Resultado do Tratamento
20.
JAMA Netw Open ; 4(6): e2112082, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-34152420

RESUMO

Importance: It is unknown whether smartphone-based virtual reality (VR) games are effective in reducing pain among pediatric patients in real-world burn clinics. Objective: To evaluate the efficacy of a smartphone VR game on dressing pain among pediatric patients with burns. Design, Setting, and Participants: This randomized clinical trial included children aged 6 to 17 years who seen in the outpatient clinic of a large American Burn Association-verified pediatric burn center and level I pediatric trauma center between December 30, 2016, and January 23, 2019. Speaking English as their primary language was an inclusion criterion. Intention-to-treat data analyses were conducted from December 2019 to March 2020. Interventions: Active VR participants played a VR game; passive VR participants were immersed in the same VR environment without interactions. Both groups were compared with a standard care group. One researcher administered VR and observed pain while another researcher administered a posttrial survey that measured the child's perceived pain and VR experience. Nurses were asked to report the clinical utility. Main Outcomes and Measures: Patients self-reported pain using a visual analog scale (VAS; range, 0-100). A researcher observed patient pain based on the Face, Legs, Activity, Cry, and Consolability-Revised (FLACC-R) scale. Nurses were asked to report VR helpfulness (range, 0-100; higher scores indicate more helpful) and ease of use (range, 0-100; higher scores indicate easier to use). Results: A total of 90 children (45 [50%] girls, mean age, 11.3 years [95% CI, 10.6-12.0 years]; 51 [57%] White children) participated. Most children had second-degree burns (81 [90%]). Participants in the active VR group had significantly lower reported overall pain (VAS score, 24.9 [95% CI, 12.2-37.6]) compared with participants in the standard care control group (VAS score, 47.1 [95% CI, 32.1-62.2]; P = .02). The active VR group also had a lower worst pain score (VAS score, 27.4 [95% CI, 14.7-40.1]) than both the passive VR group (VAS score, 47.9 [95% CI, 31.8-63.9]; P = .04) and the standard care group (VAS score, 48.8 [95% CI, 31.1-64.4]; P = .03). Simulator sickness scores (range, 0-60; lower scores indicate less sickness) were similar for active VR (19.3 [95% CI, 17.5-21.1]) and passive VR groups (19.5 [95% CI, 17.6-21.5]). Nurses also reported that the VR games could be easily implemented in clinics (helpfulness, active VR: 84.2; 95% CI, 74.5-93.8; passive VR: 76.9; 95% CI, 65.2-88.7; ease of use, active VR: 94.8, 95% CI, 91.8-97.8; passive VR: 96.0, 95% CI, 92.9-99.1). Conclusions and Relevance: In this study, a smartphone VR game was effective in reducing patient self-reported pain during burn dressing changes, suggesting that VR may be an effective method for managing pediatric burn pain. Trial Registration: ClinicalTrials.gov Identifier: NCT04544631.


Assuntos
Queimaduras/terapia , Manejo da Dor/métodos , Manejo da Dor/normas , Pediatria/normas , Guias de Prática Clínica como Assunto , Smartphone/estatística & dados numéricos , Realidade Virtual , Adolescente , Criança , Feminino , Humanos , Masculino , Inquéritos e Questionários
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