Postcesarean Analgesia With Epidural Morphine After Epidural 2-Chloroprocaine: A Randomized Noninferiority Trial.

BACKGROUND: Previous studies have suggested that administration of epidural 3% 2-chloroprocaine (CP) before epidural morphine results in decreased analgesic efficacy of epidural morphine. We sought to determine whether these observations were a result of antagonism or a window period between the conclusion of surgical anesthesia for cesarean delivery and the peak onset time of epidural morphine, and whether a method to preserve the analgesic efficacy of epidural morphine exists. METHODS: Term parturients scheduled for nonemergent, unscheduled cesarean delivery with preexisting labor epidural catheters were recruited for this exploratory, randomized, single-blinded, noninferiority trial. Subjects were randomized to initial dosing to a T4 dermatome surgical anesthetic level with either 3% CP or 2% lidocaine with 1:200,000 epinephrine and sodium bicarbonate (LEB). Subsequent redosing for both groups was performed with LEB at regular intervals. Epidural morphine 3 mg was administered to both groups after delivery. Assessing the difference between the 2 groups in total opioid use for the first 24 hours after epidural morphine administration was the primary objective. The noninferiority margin of 10 oral milligram morphine equivalents was prespecified based on previous noninferiority studies. Secondary end points included time from epidural morphine administration to first rescue opioid request, numerical pain scores, nausea/vomiting, and pruritus. RESULTS: Data were analyzed for 40 parturients, 20 in each group. The median 24-hour opioid consumption for the CP group was 0 (Q1 = 0 and Q3 = 15.6) oral milligram morphine equivalents compared to 15 (6.3-22.5) for the LEB group. The median difference was -7.5, with a 95% confidence interval -15 to 0. Noninferiority was concluded, as the confidence interval was less than the predetermined noninferiority margin of 10 oral milligram morphine equivalents. There was no treatment effect on time to first opioid request and no statistically significant differences in pain scores or nausea, vomiting, or pruritus at all time points (4, 8, 12, and 24 hours after epidural morphine administration). CONCLUSION: While designed as an exploratory study, initial epidural dosing with 3% CP and beginning subsequent redosing with LEB within 30 minutes of the initial CP bolus provided noninferior postcesarean analgesia with epidural morphine compared to initial epidural dosing and redosing with LEB. Previous observations of decreased analgesic efficacy of epidural morphine after epidural CP were likely due to a window period that may be mitigated by redosing with lidocaine; however, larger studies are necessary to confirm these findings.

Bodies in the Novel Infinite Jest.

This manuscript provides a literary analysis of the use of bodies in the novel Infinite Jest by David Foster Wallace. The novel describes a world where oversaturation of external stimulation leads to the perception of mind and body of self of an individual as prosthetic parts, malleable and deformed, wherein the mind fails to feel bodily sensations and characters experience a complete disconnectedness from the self and others. Indeed, the disembodiment of characters and sensations of disconnection leads them to a compulsive quest for connectedness through the use of masks, made-up feelings, mind-body hybrid pain, corporeal malleability, and prostheses. These portrayals of the disordered and disconnectedness between body and mind or self will be described and compared to clinical conditions characterized by a disconnection between mind and body and impaired body self-awareness. Through this exercise, we argue that the use of scientifically inspired pathologized bodies is a means of conveying the stance of Wallace on or criticism of the degradation of society through excessive entertainment.

The decision to access patient information from a social media site: what would you do?

PURPOSE: The current study examined the prevalence with which healthcare providers use a social media site (SMS) account (e.g., Facebook), the extent to which they use SMSs in clinical practice, and their decision-making process after accessing patient information from an SMS. METHODS: Pediatric faculty and trainees from a medical school campus were provided a SMS history form and seven fictional SMS adolescent profile vignettes that depicted concerning information. Participants were instructed to rate their personal use and beliefs about SMSs and to report how they would respond if they obtained concerning information about an adolescent patient from their public SMS profile. RESULTS: Healthcare providers generally believed it not to be an invasion of privacy to conduct an Internet/SMS search of someone they know. A small percentage of trainees reported a personal history of conducting an Internet search (18%) or an SMS search (14%) for a patient. However, no faculty endorsed a history of conducting searches for patients. Faculty and trainees also differed in how they would respond to concerning SMS adolescent profile information. CONCLUSIONS: The findings that trainees are conducting Internet/SMS searches of patients and that faculty and trainees differ in how they would respond to concerning profile information suggest the need for specific guidelines regarding the role of SMSs in clinical practice. Practice, policy, and training implications are discussed.

No follow-up after positive newborn screening: medical neglect?

The current study examined medical professionals' behaviors related to reporting medical neglect when a family is noncompliant with follow-up services after a positive newborn screening result. Pediatric medical professionals within an urban medical campus were provided with five case vignettes in relation to different diseases. Medical professionals rated the severity of family noncompliance with follow-up services and indicated whether they would report suspected medical neglect to Child Protective Services (CPS). Physicians were more likely to report medical neglect than the other mandated reporters in the study. Logistic regression analyses found that medical professionals' perceptions of the severity of family noncompliance with services were significantly predictive of decisions to report medical neglect. Respondent gender and the method by which families were notified of screening results also significantly affected reporting behaviors in certain instances. Although all vignettes included information that met legal statutes for reporting neglect, medical professionals indicated that they would only report neglect 40-61% of the time across vignettes. Continued investigation of the rationale behind medical professionals' decision-making process and training protocols designed to improve mandated reporter knowledge and reporting behaviors are needed to further reduce bias and improve objectivity when considering ethical and professional obligations to report medical neglect.