-
Environmental Health Perspectives Jan 2024Xenobiotic metabolites are widely present in human urine and can indicate recent exposure to environmental chemicals. Proper inference of which chemicals contribute to...
BACKGROUND
Xenobiotic metabolites are widely present in human urine and can indicate recent exposure to environmental chemicals. Proper inference of which chemicals contribute to these metabolites can inform human exposure and risk. Furthermore, longitudinal biomonitoring studies provide insight into how chemical exposures change over time.
OBJECTIVES
We constructed an exposure landscape for as many human-exposure relevant chemicals over as large a time span as possible to characterize exposure trends across demographic groups and chemical types.
METHODS
We analyzed urine data of nine 2-y cohorts (1999-2016) from the National Health and Nutrition Examination Survey (NHANES). Chemical daily intake rates (in milligrams per kilogram bodyweight per day) were inferred, using the R package bayesmarker, from metabolite concentrations in each cohort individually to identify exposure trends. Trends for metabolites and parents were clustered to find chemicals with similar exposure patterns. Exposure variation by age, gender, and body mass index were also assessed.
RESULTS
Intake rates for 179 parent chemicals were inferred from 151 metabolites (96 measured in five or more cohorts). Seventeen metabolites and 44 parent chemicals exhibited fold-changes between any two cohorts (deltamethrin, di--octyl phthalate, and di-isononyl phthalate had the greatest exposure increases). Di-2-ethylhexyl phthalate intake began decreasing in 2007, whereas both di-isobutyl and di-isononyl phthalate began increasing shortly before. Intake for four parabens was markedly higher in females, especially reproductive-age females, compared with males and children. Cadmium and arsenobetaine exhibited higher exposure for individuals years of age and lower for individuals years of age.
DISCUSSION
With appropriate analysis, NHANES indicates trends in chemical exposures over the past two decades. Decreases in exposure are observable as the result of regulatory action, with some being accompanied by increases in replacement chemicals. Age- and gender-specific variations in exposure were observed for multiple chemicals. Continued estimation of demographic-specific exposures is needed to both monitor and identify potential vulnerable populations. https://doi.org/10.1289/EHP12188.
Topics: Child; Female; Male; Humans; Biological Monitoring; Nutrition Surveys; Body Mass Index; Cadmium; Phthalic Acids
PubMed: 38285237
DOI: 10.1289/EHP12188 -
Harm Reduction Journal Aug 2023Drug consumption rooms offer heroin and cocaine consumers a secure and hygienic environment including medical and social guidance. Despite the support and mentoring,...
BACKGROUND
Drug consumption rooms offer heroin and cocaine consumers a secure and hygienic environment including medical and social guidance. Despite the support and mentoring, only sparse information is available about how drug quality, drug prices and user expectations match at these locations. The present study reports analysis of these three parameters in two drug consumption rooms in Luxembourg.
METHODS
Drug users were invited to participate in the project by handing in a few milligrams of the product they planned to consume for chemical analysis and filling out a short questionnaire about the price and their expectations. After consumption, they were asked to report the experienced effects. Drug quality was accessed using LC-Q-ToF and HPLC-UV, and a statistical analysis was carried out of the questionnaires that were correctly filled out.
RESULTS
A total of 513 drug samples have been analyzed. Most consumers were looking for the relaxing/calming effects of heroin and the stimulating effects of cocaine, but they generally overestimated heroin potency and underestimated cocaine potency. No strong correlation based on Spearman's ρ between drug user estimations, drug prices and drug quality was found.
CONCLUSION
To the best of our knowledge, this study is the first to combine drug analysis with heroin and cocaine user feedback about expectation, drug prices and drug effects. The analytical results were of great interest for users and the staff working at the drug consumption rooms. They may be a strong supplementary communication tool for health care workers when discussing effects and risks of highly toxic substance consumption.
Topics: Humans; Cocaine; Heroin; Motivation; Drug Users; Surveys and Questionnaires
PubMed: 37542248
DOI: 10.1186/s12954-023-00837-3 -
Cureus Mar 2024Introduction Understanding the different opioid pain relief requirements between patients with upper limb fractures can be useful in forming specific evidence-based...
Introduction Understanding the different opioid pain relief requirements between patients with upper limb fractures can be useful in forming specific evidence-based guidelines and balancing patient-clinician prescribing discussions with opioid stewardship. We investigated the predictors for opioid requirements in upper limb fractures. Methods We retrospectively investigated all upper limb fractures from the shoulder to the wrist treated at a major trauma center from January 2015 to January 2022. The data collected consisted of fracture location, demographics, comorbidities, and management options. Post-injury opioid prescriptions in the first post-injury year were calculated every month up to six months and then grouped from the seventh to the 12th month and converted to morphine milligram equivalents (MMEs). We then calculated days requiring at least one medication (representing the "coverage") and relative "strength" in each time period. Results Six thousand four hundred thirteen patients sustaining a combined 9125 fractures were included in the study, with an MME mean of 436. Fracture locations of the scapula, proximal humerus, humeral shaft, distal humerus, and proximal ulna all had significantly higher MME requirements (p<0.05) at the one-year level. The radius shaft and distal radius had significantly lower MME requirements (p<0.05). The patients with depression, diabetes, drug abuse history, obesity, pulmonary circulatory disorder, and rheumatological conditions required higher strength of opioids at the one-year level (p<0.05). The patients with chronic kidney disease, depression, pulmonary circulation disorder, and rheumatological conditions required higher coverage of opioids at the one-year level (p<0.05). Conclusion Our study presents a high-resolution breakdown of the post-injury opioid requirements for patients with upper limb injuries. Fractures of the scapula, proximal humerus, and shaft of the humerus were associated with increases in both opioid strength and coverage. Depression, pulmonary disease, and rheumatological conditions were all associated with increased opioid strength and coverage. This provides a framework for which clinicians and patients can more accurately anticipate the course of the rehabilitation journey and risk stratify appropriately at the outset of injury.
PubMed: 38638745
DOI: 10.7759/cureus.56499 -
MedRxiv : the Preprint Server For... Oct 2023Pain is a common, debilitating, and poorly understood complication of sickle cell disease (SCD). The need for clinical pain management of SCD is largely unmet and relies...
BACKGROUND
Pain is a common, debilitating, and poorly understood complication of sickle cell disease (SCD). The need for clinical pain management of SCD is largely unmet and relies on opioids as the main therapeutic option, which leads to a decreased quality of life (QoL). According to the literature, acupuncture has shown certain therapeutic effects for pain management in SCD. However, these clinical studies lack the guidance of Traditional Chinese Medicine (TCM) Syndrome Differentiation principles for treatment.
AIM
To characterize differences in clinical presentation amongst TCM-diagnosed syndromes in SCD patients.
METHOD
52 patients with SCD and 28 age- and sex-matched healthy controls (HCs) were enrolled in an ongoing trial of acupuncture. Each participant completed a series of questionnaires on pain, physical function, fatigue, sleep, anxiety, depression, and QoL and underwent cold- and pressure-based quantitative sensory testing at baseline. Data on prescription opioid use over the 12 months prior to study enrollment was used to calculate mean daily morphine milligram equivalents (MME). Differences among the three TCM syndromes were analyzed by one-way ANOVA followed by Tukey post hoc testing. Two-sample t-tests were used to compare SCD and HC groups.
RESULTS
TCM diagnosis criteria classified SCD patients into one of three TCM syndromes: a) Equal; b) Deficiency; and c) Stagnation. The Stagnation group exhibited higher pain interference, physical dysfunction, nociplastic pain, fatigue, anxiety, depression, MME consumption, and lower sleep quality and QoL compared to the Equal group. Few differences were observed between HCs and the Equal SCD group across outcomes. Deficiency and Stagnation groups were differentiated with observed- and patient-reported clinical manifestations.
CONCLUSION
These findings suggest that TCM-diagnosed syndromes in SCD can be differentially characterized using validated objective and patient-reported outcomes. Because characteristics of pain and co-morbidities in each SCD patient are unique, targeting specific TCM "syndromes" may facilitate treatment effectiveness with a syndrome-based personalized treatment plan that conforms to TCM principles. These findings lay the foundation for the development of tailored acupuncture interventions based on TCM syndromes for managing pain in SCD. Larger samples are required to further refine and validate TCM diagnostic criteria for SCD.
PubMed: 37905075
DOI: 10.1101/2023.10.08.23296714 -
The Journal of the American Academy of... Sep 2023Posterior lumbar fusion surgery has become more common amid an aging population, with degenerative disease as its most common indication. Historically, postoperative... (Randomized Controlled Trial)
Randomized Controlled Trial
INTRODUCTION
Posterior lumbar fusion surgery has become more common amid an aging population, with degenerative disease as its most common indication. Historically, postoperative pain control for spine surgery has relied on opioids. However, opioid use is associated with adverse effects such as dependence, respiratory depression, and altered cognition. Our study aimed to determine whether an opioid-sparing multimodal analgesia regimen (ketorolac, orphenadrine, and gabapentin) could be a viable alternative to diminish opioid use compared with a standard opioid-based regimen in Hispanic patients undergoing posterior lumbar spinal fusion.
METHODS
This was a randomized controlled trial of Hispanic patients scheduled to undergo elective posterior spinal fusion. Inclusion criteria included age 30 to 85 years, Hispanic ethnicity, lumbar stenosis between L1 and S1, elective posterior spinal fusion with instrumentation, American Society of Anesthesiologists Score <2, and consent to participate in the study. Patients were randomized into two groups, an experimental multimodal analgesia and control (opioid-based) treatment groups, and outcomes such as morphine milligram equivalents used, visual analog scale score, and length of hospital stay were compared between the groups.
RESULTS
The MMA experimental group used significantly lower amounts of opioid (measured with morphine milligram equivalent) than the opioid-based group during the 12-hour and 24-hour postoperative periods ( P -value = 0.023 and P -value = 0.033, respectively). No statistically significant difference was observed in opioid use in the 48-hour postoperative period between both groups ( P -value = 0.066). The MMA group had significantly lower VAS scores reported at the 12-hour, 24-hour, and 48-hour postoperative periods compared with the opioid-based group ( P -values = 0.016, 0.020, and 0.020, respectively). No difference was observed in the length of hospital stay between groups ( P -value = 0.169).
DISCUSSION
Implementing an MMA protocol in Hispanic patients undergoing posterior lumbar fusion resulted in decreased overall opioid use and decreased pain intensity compared with the opioid-based group. MMA is an effective alternative for pain control in patients who want to avoid opioid use.
CLINICAL TRIAL REGISTRATION
Identifier: NCT05413902.
Topics: Adult; Aged; Aged, 80 and over; Humans; Middle Aged; Analgesia; Analgesics, Opioid; Hispanic or Latino; Morphine Derivatives; Pain, Postoperative; Spinal Fusion
PubMed: 37192425
DOI: 10.5435/JAAOS-D-22-00878 -
Journal of Opioid Management 2023To investigate post-operative opioid use following a total hip arthroplasty (THA) in metastatic bone disease (MBD) patients and identify factors associated with...
OBJECTIVES
To investigate post-operative opioid use following a total hip arthroplasty (THA) in metastatic bone disease (MBD) patients and identify factors associated with post-operative opioid use at 6 weeks and 90 days.
BACKGROUND
MBD commonly affects the hip, and surgical intervention including THA may be indicated for pain relief or to improve function. Following THA, patients are often prescribed short courses of opioids for post-operative pain relief. No study has evaluated opiate use following THA in patients for MBD.
METHODS
This was a retrospective review of patients using opioids preoperatively who underwent primary THA for MBD at two institutions between 2009 and 2022. Preoperative and post-operative opioid usages, respectively, at 6 weeks and 90 days were quantified through calculating daily morphine milligram equivalents (MMEs) and compared using the sign test. Factors associated with post-operative opioid use at 6 weeks and 90 days were compared using χ2 test or Fisher's exact test as appropriate.
RESULTS
Nineteen THA and 11 THA with complex acetabular reconstruction were included. At 6 weeks, 26 (86.7 percent) patients were utilizing opiates, and at 90 days, 23 (76.7 percent) patients were utilizing opiates. There was a statistically significant difference between median daily preoperative MME compared to daily MME at 90 days (p < 0.001). The only statistically significant association with opioid use at 90 days was opioid use at 6 weeks.
CONCLUSION
To our knowledge, this is the first paper evaluating post-operative opioid use following primary THA in MBD patients. After THA in the setting of MBD, patients exhibit decreased post-operative opioid use. Future studies with larger cohorts should be conducted to characterize post-operative opioid use following joint arthroplasty in MBD patients.
Topics: Humans; Arthroplasty, Replacement, Hip; Analgesics, Opioid; Opiate Alkaloids; Pain, Postoperative; Opioid-Related Disorders; Retrospective Studies; Bone Diseases; Endrin
PubMed: 37968973
DOI: 10.5055/jom.0813 -
JSES International Nov 2023Various studies have examined the relationship between preoperative mental health diagnoses (MHDs) and postoperative outcomes in orthopedic shoulder patients. However,...
BACKGROUND
Various studies have examined the relationship between preoperative mental health diagnoses (MHDs) and postoperative outcomes in orthopedic shoulder patients. However, few investigations delve into the relationship between a preoperative MHD and postoperative opioid pain control regimens in patients who have undergone rotator cuff repair (RCR), total shoulder arthroplasty (TSA), and reverse TSA (rTSA). We hypothesize that orthopedic shoulder patients with a preoperative MHD will be prescribed more opioids (ie, request more refills) postoperatively than those without a MHD.
METHODS
An institutional review board-approved retrospective chart review was performed on 438 patients, 18 years or older, who underwent RCR, TSA, or rTSA. Patients were divided into two groups: those diagnosed with depression, anxiety, bipolar disorder, and/or schizophrenia (n = 193), and those with no previous MHD (n = 245). Statistical outcomes were analyzed with the independent -test, Mann-Whitney U test, one-way Analysis of Variance, and Kruskal-Wallis test.
RESULTS
Univariate analysis demonstrated significant differences between the MHD group and non-MHD group in average 90-day postoperative opioid scripts (2.10 vs. 1.55, respectively, < .001) and median 90-day postoperative morphine milligram equivalents (MMEs) prescribed (225 MME vs. 185.25 MME, respectively, < .001). Among patients who were opioid naive 90 days preoperatively, significant differences were found in MMEs prescribed between the MHD and non-MHD group (225 MME vs. 150 MME, respectively, < .001). Further analysis of opioid naive patients with specifically depression compared to patients with an alternate or no MHD diagnosis yielded significant differences in scripts (1.78 vs. 1.33, respectively, = .031) and MMEs prescribed (225 MME vs. 150 MME, respectively, < .001).
CONCLUSION
This study found that RCR, TSA, or rTSA patients with a preoperative MHD were prescribed significantly more postoperative MMEs and more opioid scripts (ie, requested more refills) than those without MHD. This is despite preoperative education on postoperative pain expectations and limiting opioid use. Our findings support our hypothesis and emphasize the clinical importance of recognizing mental health disease while navigating postoperative pain control expectations. Given the rising prevalence of mental health disorders nationwide, considering the effect of these comorbidities on postoperative pain in RCR, TSA, and rTSA patients will be essential to enhance preoperative and postoperative counseling and management by orthopedic surgeons. We further recommend a multidisciplinary approach to help manage pain in these patients.
PubMed: 37969524
DOI: 10.1016/j.jseint.2023.06.013 -
Spine Nov 2023Retrospective cohort study.
Evidence for a Multimodal Pain Management Regimen in Reduction of Postoperative Opioid Use in Pediatric Patients Receiving Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.
STUDY DESIGN
Retrospective cohort study.
OBJECTIVE
This project aims to evaluate the relationship between increased use of intraoperative nonopioid analgesics, muscle relaxers, and anesthetics and postoperative outcomes, including opioid utilization, time until ambulation, and hospital length of stay.
SUMMARY OF BACKGROUND DATA
Adolescent idiopathic scoliosis (AIS) is a structural deformity of the spine that occurs in otherwise healthy adolescents, occurring with a frequency of 1% to 3%. Up to 60% of patients receiving spinal surgeries, particularly posterior spinal fusion (PSF), experience at least 1 day of moderate-to-severe pain after surgery.
PATIENTS AND METHODS
This is a retrospective chart review of pediatric patients aged 10 to 17 having received PSF with >5 levels fused for AIS at a dedicated children's hospital and a regional tertiary referral center with a dedicated pediatric spine program between January 2018 and September 2022. A linear regression model was used to evaluate the influence of baseline characteristics and intraoperative medications on the total amount of postoperative morphine milligram equivalents received.
RESULTS
There were no significant differences in the background characteristics of the two patient populations. Patients receiving PSF at the tertiary referral center received equivalent or greater amounts of all nonopioid pain medications and demonstrated decreased time until ambulation (19.3 vs . 22.3 h), postoperative opioid use (56.1 vs . 70.1 MME), and postoperative hospital length of stay (35.9 vs . 58.3 h). Hospital location was not individually associated with a difference in postoperative opioid use. There was not a significant difference in postoperative pain ratings. When accounting for all other variables, liposomal bupivacaine had the greatest contribution to the decrease in postoperative opioid use.
CONCLUSION
Patients receiving greater amounts of nonopioid intraoperative medications utilized 20% fewer postoperative morphine milligram equivalents, were discharged 22.3 hours earlier and had earlier recorded evidence of mobility. Postoperatively, nonopioid analgesics were as effective as opioids in the reduction of subjective pain ratings. This study further demonstrates the efficacy of multimodal pain management regimens in pediatric patients receiving PSF for AIS.
Topics: Humans; Adolescent; Child; Analgesics, Opioid; Pain Management; Retrospective Studies; Analgesics, Non-Narcotic; Scoliosis; Spinal Fusion; Pain, Postoperative; Opioid-Related Disorders; Morphine Derivatives
PubMed: 37294836
DOI: 10.1097/BRS.0000000000004747 -
Journal of Clinical Anesthesia Dec 2023Poorly controlled acute postsurgical pain is associated with delayed recovery, chronic postsurgical pain (CPSP), chronic opioid use and impaired functioning in daily...
The effectiveness of a transitional pain service in patients undergoing surgery with an increased risk of developing chronic postsurgical pain (TRUSt study). A randomized clinical trial.
STUDY OBJECTIVE
Poorly controlled acute postsurgical pain is associated with delayed recovery, chronic postsurgical pain (CPSP), chronic opioid use and impaired functioning in daily activities. The aim was to determine the effectiveness of a transitional pain service (TPS) to improve quality of recovery for patients at risk of CPSP. We hypothesized that a TPS improves the quality of recovery in patients at risk of CPSP.
DESIGN
Single-center, pragmatic, randomized, superiority trial.
SETTING
Tertiary hospital in the Netherlands.
PATIENTS
Assessed for eligibility if ≥18 years of age, undergoing elective surgery, and had an increased risk of developing CPSP. After being stratified for sex, 176 patients were included.
INTERVENTION
Patients were randomized to receive TPS or standard of care (SOC). TPS was a multidisciplinary intervention providing a patient-tailored perioperative pain management plan, throughout all phases of surgery.
MEASUREMENTS
The primary outcome was the difference in quality of recovery on the third postoperative day, measured by the Quality of Recovery (QoR)-15 questionnaire. Secondary outcomes include the between group differences in opioid consumption.
MAIN RESULTS
The primary outcome was available in 169 (96.0%) patients. No difference between groups was found in QoR-15 on the third postoperative day (mean difference 2.0, 95% CI -5.5 to 9.4, p = 0.607). A decrease in opioid usage (compared to baseline) was observed in chronic opioid users, the median [IQR] reduction in total daily oral morphine milligram equivalents (MME) for TPS was -30 [-60, 0] at three and - 29.3 [-65.6, 0] at six months, whereas SOC had a median reduction of 0 [-56, 0] at three, and 0 [-60, 7.5] at six months.
CONCLUSIONS
TPS did not significantly affect short-term quality of recovery but might improve long-term outcomes, such as the incidence of chronic pain, opioid consumption, and functioning in daily life. However, sample size in the present study was too small to provide solid evidence for this positive signal.
PubMed: 37722149
DOI: 10.1016/j.jclinane.2023.111262 -
European Journal of Orthopaedic Surgery... Jul 2023The purpose of this study was to analyze the patient/injury characteristics and associated hospital course of patients sustaining traumatic pelvic ring injuries after...
PURPOSE
The purpose of this study was to analyze the patient/injury characteristics and associated hospital course of patients sustaining traumatic pelvic ring injuries after alpine ski and snowboard accidents at a level one trauma center in the Rocky Mountain region.
METHODS
Patient/injury characteristics were obtained from patients presenting with pelvic ring injuries after alpine ski (n = 55) and snowboard (n = 9) accidents. Characteristics and outcomes analyzed included mechanism of injury, pelvic ring classification (Young-Burgess and Tile), hospital admission, physical therapy (PT) clearance, ambulation, length of stay, inpatient morphine milligram equivalents (MME), and discharges to rehabilitation facility.
RESULTS
Snowboarders were more often younger, male, tobacco/substance users, and more likely to be injured by a fall from height than skiers. There were no differences in injury classification or hospital course outcomes between alpine sports. Most common injuries included lateral compression type 1 (LC1) injuries (37.5%), isolated pubic ramus fractures (31.3%), and isolated iliac wing fractures (15.6%). LC1 injuries were unstable in 50% of cases and associated with increased admissions (proportional difference: 47.5%, CI: 23.8-64.5%, p = 0.0002), longer time to PT clearance (median difference(MD): 1.0 day, CI: 0-2.0, p = 0.03), longer LOS (MD: 2.0, CI: 0-2.0, p = 0.02), and increased inpatient MMEs (MD: 197.9 MME, CI: 30.0-420.0, p = 0.02), as compared to other pelvic ring injuries.
CONCLUSION
The majority of pelvic ring injuries from alpine ski and snowboard accidents were LC1 injuries, half of which were unstable, resulting in longer hospital stays, time to PT clearance/ambulation, and opioid use.
Topics: Humans; Male; Skiing; Fractures, Bone; Spinal Fractures; Accidents; Crush Injuries; Hip Injuries
PubMed: 35831489
DOI: 10.1007/s00590-022-03331-x